=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902585516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLOS NIEVES MASSAGE THERAPIST
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2023
-----------------------------------------------------
Last Update Date | 07/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 EGAN DR
-----------------------------------------------------
City | SAVAGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55378-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-363-0219
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4401 EGAN DR
-----------------------------------------------------
City | SAVAGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55378-2024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-363-0219
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------