=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730899444
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAMIEN A ARCHAMBEAU LMT, CLT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2022
-----------------------------------------------------
Last Update Date | 12/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 SAVAGE CT
-----------------------------------------------------
City | FALLING WATERS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25419-1469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-842-4606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58 SAVAGE CT
-----------------------------------------------------
City | FALLING WATERS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25419-1469
-----------------------------------------------------
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 | M06141
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0019016915
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 2017-3502
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------