=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629353008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CENTER FOR MASSAGE THERAPY, COOPER CITY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2011
-----------------------------------------------------
Last Update Date | 10/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9850 STIRLING RD SUITE 102
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-434-1990
-----------------------------------------------------
Fax | 954-433-4475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9850 STIRLING RD SUITE 102
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-434-1990
-----------------------------------------------------
Fax | 954-433-4475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED THERAPIST
-----------------------------------------------------
Name | MR. DENNIS P. FARRETTA
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 954-434-1990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | MA9569
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | AP3017
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------