=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669862843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT METROPOLITAN BACKRUB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2015
-----------------------------------------------------
Last Update Date | 04/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 762 CLEVELAND AVE S
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55116-1347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-698-3338
-----------------------------------------------------
Fax | 612-729-1403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 762 CLEVELAND AVE S
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55116-1347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-698-3338
-----------------------------------------------------
Fax | 612-729-1403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | BARRY WOLF
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 239-970-2484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------