=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619480878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEILA M PERCY MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2017
-----------------------------------------------------
Last Update Date | 11/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 SCHOOL ST STE 102
-----------------------------------------------------
City | ROCKLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04841-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-594-0060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 TALBOT AVE
-----------------------------------------------------
City | ROCKLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04841-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-594-0060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. LEILA M PERCY
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 207-594-0060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT2205
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------