=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710336995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASSAGE MATTERS MICHIGAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2016
-----------------------------------------------------
Last Update Date | 06/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21331 KELLY RD
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-293-9427
-----------------------------------------------------
Fax | 866-466-3087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13960 METTETAL ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48227-1747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-586-2026
-----------------------------------------------------
Fax | 866-466-3087
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | MS. SHERITTA MARIE BUFORD
-----------------------------------------------------
Credential | L.M.T
-----------------------------------------------------
Telephone | 313-293-1054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | 7501009330
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------