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General NPI Number Information
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NPI Number | 1740912369
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Entity Type | Individual
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Provider Name | BLADIMIR MARTE MASSAGE THERAPY
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Gender | Male
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Dates
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Enumeration Date | 06/30/2022
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Last Update Date | 06/30/2022
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Provider Practice Location Address
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Address Line | 1849 N 1120 W
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City | PROVO
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State | UT
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Zip | 84604-1180
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Country | US
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Telephone | 801-960-8789
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Fax |
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Provider Business Mailing Address
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Address Line | 124 W 1435 S
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City | OREM
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State | UT
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Zip | 84058-7467
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Country | US
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Telephone | 908-838-2092
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 11343515-4701
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License Number State | UT
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