=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720277809
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON PERINGER ATC, CSCS, LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2007
-----------------------------------------------------
Last Update Date | 10/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 MAIN ST # 334
-----------------------------------------------------
City | VINEYARD HAVEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02568-0334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-693-8020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 76 MAIN ST # 334
-----------------------------------------------------
City | VINEYARD HAVEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02568-0334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA28173
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------