=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598350993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAKERA'S THERAPEUTIC MASSAGE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2021
-----------------------------------------------------
Last Update Date | 03/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26150 5 MILE RD STE 1D
-----------------------------------------------------
City | REDFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48239-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-676-8889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26150 5 MILE RD STE 1D
-----------------------------------------------------
City | REDFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48239-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-676-8889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TAKERA LAWERY
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 131-367-6888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------