=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841571239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGEA MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2011
-----------------------------------------------------
Last Update Date | 08/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5069 W 13400 S STE 100
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-253-8141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5069 W 13400 S STE 100
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GABRIELA AGUILLON
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 801-888-1818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 2011147
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------