=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548583958
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASSAGECRAFT INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2010
-----------------------------------------------------
Last Update Date | 03/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 ALFRED ST
-----------------------------------------------------
City | BIDDEFORD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04005-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-286-8416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 314 ALFRED ST
-----------------------------------------------------
City | BIDDEFORD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04005-3102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-286-8416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, ACUPUNCTURIST, MASSAGE THERA
-----------------------------------------------------
Name | LISA ANNE BOUCHARD
-----------------------------------------------------
Credential | LMT, LAC
-----------------------------------------------------
Telephone | 207-286-8416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT410
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC209
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------