MEDICARE: BREATH OF LIFE WELLNESS SPA, LLC

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	0019006317	VA

General Provider Information

NPI Number	:	1063752657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREATH OF LIFE WELLNESS SPA, LLC

Provider Business Mailing Address
First Line	:	5300 KEMPSRIVER DR
Second Line	:	SUITE 106
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5369
Country	:	US
Telephone Number	:	757-390-4136
Fax Number	:

Provider Business Practice Location Address
First Line	:	5300 KEMPSRIVER DR
Second Line	:	SUITE 106
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5369
Country	:	US
Telephone Number	:	757-390-4136
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ANGELA SHOWERS
Credential	:	LMT
Telephone Number	:	757-390-4136

Provider Enumeration Date	:	02/19/2013
Last Update Date	:	02/19/2013

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