=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881184844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAHOGANY WOOLFOLK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2018
-----------------------------------------------------
Last Update Date | 05/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1221 MALL DR STE 202
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-4737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-569-5184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1221 MALL DR STE 202
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-4737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-569-5184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAHOGANY WOOLFOLK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-569-5184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0019011549
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------