MEDICARE: DEEP TISSUE MASSAGE GROUP, INC.

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

General Provider Information

NPI Number	:	1184195182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEEP TISSUE MASSAGE GROUP, INC.

Provider Business Mailing Address
First Line	:	725 W ALDER ST STE 20
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59802-4099
Country	:	US
Telephone Number	:	406-493-1115
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 W ALDER ST STE 20
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59802-4099
Country	:	US
Telephone Number	:	406-493-1115
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	CAMARIN METCALF
Credential	:	L.M.T.
Telephone Number	:	406-493-1115

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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