=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629702931
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAINE PHOENIX STERLING MT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2022
-----------------------------------------------------
Last Update Date | 07/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8912 E SHANGRI LA RD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-877-1004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8912 E SHANGRI LA RD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-6182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-877-1004
-----------------------------------------------------
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 | 28632
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------