=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912139676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAYTON MEDICAL MASSAGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2009
-----------------------------------------------------
Last Update Date | 08/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 BIRCH ALY SUITE 240
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-1479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-271-7072
-----------------------------------------------------
Fax | 937-660-6378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 BIRCH ALY SUITE 240
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-1479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-271-7072
-----------------------------------------------------
Fax | 937-660-6378
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LMT
-----------------------------------------------------
Name | MRS. RAYNA MARIE HALL
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 937-271-7072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 33. 016347
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------