=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952784563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDEFINE RELIEF, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2015
-----------------------------------------------------
Last Update Date | 06/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11859 PECOS ST
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80234-2741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-351-5245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 352076
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80035-2076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | SHANNON GLORIOSO
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 312-351-5245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 15496
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------