=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699326298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMUM PERFORMANCE THERAPEUTIC MASSAGE & BODYWORK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2019
-----------------------------------------------------
Last Update Date | 06/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 MAIN ST S
-----------------------------------------------------
City | SOUTHBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06488-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-707-1013
-----------------------------------------------------
Fax | 203-405-1798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 MAIN ST S
-----------------------------------------------------
City | SOUTHBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06488-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-707-1013
-----------------------------------------------------
Fax | 203-405-1798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID GASSNER
-----------------------------------------------------
Credential | LMT, CLT
-----------------------------------------------------
Telephone | 203-707-1013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------