=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912327628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN E MCCOY SR. LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2014
-----------------------------------------------------
Last Update Date | 04/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1166 E WARNER RD SUITE 101
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-3064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-220-6407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13327 E CHICAGO ST
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-220-6407
-----------------------------------------------------
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 | MT-17802
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------