=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558897538
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAYA'S MASSAGE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 05/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1955 DOGWOOD DR
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95403-1577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-342-1345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 860 PETALUMA BLVD N SUITE E
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-342-1345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. MAYA NICHOLLS
-----------------------------------------------------
Credential | CMT
-----------------------------------------------------
Telephone | 415-342-1345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 16356
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------