=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699301168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERRICK MASSAGE THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2020
-----------------------------------------------------
Last Update Date | 03/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 BROADWAY RM 1115
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-4375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-962-2262
-----------------------------------------------------
Fax | 646-607-4412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 BROADWAY RM 1115
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-4375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-962-2262
-----------------------------------------------------
Fax | 646-607-4412
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GARY LEVITON
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 212-962-2262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------