MEDICARE: SHANNON LEIGH CLARK D/B/A MASSAGE MATTERS 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	8598	TN

General Provider Information

NPI Number	:	1104348820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LEIGH CLARK D/B/A MASSAGE MATTERS LMT

Provider Business Mailing Address
First Line	:	1219 UPLAND AVE
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37743-6641
Country	:	US
Telephone Number	:	423-278-8168
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 OLD STAGE RD STE A
Second Line	:
City	:	GREENEVILLE
State	:	TN
Zip	:	37745-3117
Country	:	US
Telephone Number	:	423-278-8168
Fax Number	:

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

Provider Enumeration Date	:	07/14/2017
Last Update Date	:	03/17/2018

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