=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619728789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYOCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2024
-----------------------------------------------------
Last Update Date | 03/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3724 VEST MILL RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-782-6199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3724 VEST MILL RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-2912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-782-6199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | DEBRA GARNER
-----------------------------------------------------
Credential | LMBT
-----------------------------------------------------
Telephone | 336-782-6199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------