MEDICARE: GENA EDWARDS LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	27649	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27649	OTHER	AZ	MASSAGE LICENSE

General Provider Information

NPI Number	:	1063188092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENA EDWARDS LMT

Provider Business Mailing Address
First Line	:	1621 W VILLAGE WAY
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-4445
Country	:	US
Telephone Number	:	602-456-1662
Fax Number	:

Provider Business Practice Location Address
First Line	:	1621 W VILLAGE WAY
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-4445
Country	:	US
Telephone Number	:	602-456-1662
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2021
Last Update Date	:	08/19/2021

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Directions to “ GENA EDWARDS LMT” Practice Location

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