MEDICARE: MR. GREGGORY THOMAS GAUSDEN 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	3991	NE

General Provider Information

NPI Number	:	1184324311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGGORY THOMAS GAUSDEN LMT

Provider Business Mailing Address
First Line	:	6819 S 167TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68135-5401
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6819 S 167TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68135-5401
Country	:	US
Telephone Number	:	531-375-5673
Fax Number	:

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

Provider Enumeration Date	:	03/07/2023
Last Update Date	:	03/07/2023

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