=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558684548
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JA SPA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2010
-----------------------------------------------------
Last Update Date | 03/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 W MAIN ST
-----------------------------------------------------
City | MARCELLUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13108-1118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-673-3838
-----------------------------------------------------
Fax | 315-673-3866
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 W MAIN ST
-----------------------------------------------------
City | MARCELLUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13108-1118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-673-3838
-----------------------------------------------------
Fax | 315-673-3866
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE SECRETARY
-----------------------------------------------------
Name | PATRICIA ANN PHILLIPS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-673-3838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------