=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619168531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK E HARRIS LIC MASSAGE THERAPIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 08/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2400 DIAGONAL RD
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-7619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-784-4471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1314 JOHNSON ST
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54601-5616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-784-4471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 2914 046
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------