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General NPI Number Information
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NPI Number | 1760811400
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Entity Type | Organization
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Legal Business Name | MEDISAGE, LLC
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Dates
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Enumeration Date | 11/04/2013
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Last Update Date | 11/04/2013
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Provider Practice Location Address
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Address Line | 5016 S ASH AVE SUITE 105
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City | TEMPE
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State | AZ
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Zip | 85282-6845
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Country | US
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Telephone | 623-295-9001
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Fax |
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Provider Business Mailing Address
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Address Line | 2602 N 87TH TER
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City | SCOTTSDALE
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State | AZ
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Zip | 85257-1844
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Country | US
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Telephone | 623-295-9001
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | MR. JOHN M BONK
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Credential | LMT
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Telephone | 623-295-9001
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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 | MT-18159
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License Number State | AZ
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