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General NPI Number Information
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NPI Number | 1639666506
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Entity Type | Organization
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Legal Business Name | MEDSPORT MASSAGE, LLC
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Dates
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Enumeration Date | 04/17/2018
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Last Update Date | 04/17/2018
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Provider Practice Location Address
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Address Line | 39 RIVER ROAD SUITE 1
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City | NEW CASTLE
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State | ME
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Zip | 04553-0074
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Country | US
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Telephone | 207-807-7465
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Fax | 207-882-7439
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Provider Business Mailing Address
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Address Line | MEDSPORT MASSAGE PO BOX 74
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City | NEW CASTLE
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State | ME
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Zip | 04553-0074
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Country | US
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Telephone | 207-807-7465
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Fax | 207-882-7439
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Authorized Official
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Title or Position | OWNER OF MEDSPORT MASSAGE
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Name | MS. SUSAN M PETERS
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Credential | LICENSED MASSAGE THE
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Telephone | 207-807-7465
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT4833
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License Number State | ME
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