=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629532684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES M DANE LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2019
-----------------------------------------------------
Last Update Date | 01/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6203 ABERCORN ST STE 103E
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31405-5597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-231-9298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6203 ABERCORN ST STE 103E
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31405-5597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-231-9298
-----------------------------------------------------
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 | MT001308
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------