=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972228997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYOGRASP BODYWORK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 10/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 W ROBERT BUSH DR
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-627-7636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 769
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98586-0769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-627-7637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL MASSAGE PRACTITIONER
-----------------------------------------------------
Name | RAMONA MICHAELA SHATRAW
-----------------------------------------------------
Credential | MMP
-----------------------------------------------------
Telephone | 208-627-7637
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------