=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740788363
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGIANA CAMPOS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2018
-----------------------------------------------------
Last Update Date | 01/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11890 W 64TH AVE
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80004-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-212-6151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11890 W 64TH AVE
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80004-4324
-----------------------------------------------------
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 | 0016987
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------