MEDICARE: DWAY EASTERN THERAPEUTIC BODYWORK 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	133N00000X	Nutritionist
2	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1073465753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DWAY EASTERN THERAPEUTIC BODYWORK LLC

Provider Business Mailing Address
First Line	:	7600 BASS LAKE RD
Second Line	:
City	:	NEW HOPE
State	:	MN
Zip	:	55428-3860
Country	:	US
Telephone Number	:	612-249-3132
Fax Number	:	612-249-3132

Provider Business Practice Location Address
First Line	:	7600 BASS LAKE RD
Second Line	:
City	:	NEW HOPE
State	:	MN
Zip	:	55428-3860
Country	:	US
Telephone Number	:	612-249-3132
Fax Number	:	612-249-3132

Authorized Official
Title or Position	:	CEO
Name	:	DENISE ANTIONETTE FRAZIER
Credential	:
Telephone Number	:	612-249-3132

Provider Enumeration Date	:	02/13/2026
Last Update Date	:	02/13/2026

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