=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669692117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MASSAGE HEALTHCARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 08/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 CALVERT ST 34
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68506-5797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-423-2643
-----------------------------------------------------
Fax | 402-423-2644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3601 CALVERT ST
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-423-2643
-----------------------------------------------------
Fax | 402-423-2644
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRADLEY DEAN DECKER
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 402-423-2643
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 1234
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------