=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568739860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL MASSAGE & WELLNESS CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2011
-----------------------------------------------------
Last Update Date | 11/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 832 W EISENHOWER BLVD SUITE B-1
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80537-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-667-2277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 832 W EISENHOWER BLVD SUITE B-1
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80537-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-667-2277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. ROBYN L DAVIS
-----------------------------------------------------
Credential | RMT
-----------------------------------------------------
Telephone | 970-667-2277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------