=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598214207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY HEALTH MASSAGE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2016
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1701 S 17TH ST STE 2E
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68502-2641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-617-3604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4115 N 20TH ST
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68521-1512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-617-3604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | PEGGY E BELGUM
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 402-617-3604
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 2124
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------