=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588154512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A QUEENS TOUCH THERAPEUTIC MASSAGE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2018
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 158 LANTERN LN
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-3254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-308-0892
-----------------------------------------------------
Fax | 657-202-8376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 158 LANTERN LN
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-3254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-308-0892
-----------------------------------------------------
Fax | 657-202-8376
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASSAGE THERAPIST
-----------------------------------------------------
Name | YOLANDA BOLDING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-308-0892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 16400
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------