MEDICARE: ASHLEY MICHELLE MACK 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NVMT10083	OTHER	NV	STATE LICENSE
2	MT014566	OTHER	GA	STATE LICENSE

General Provider Information

NPI Number	:	1194324616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY MICHELLE MACK LMT

Provider Business Mailing Address
First Line	:	649 LINESHACK LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-2110
Country	:	US
Telephone Number	:	702-715-7112
Fax Number	:

Provider Business Practice Location Address
First Line	:	9525 HILLWOOD DR STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-0596
Country	:	US
Telephone Number	:	702-642-5446
Fax Number	:

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

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	05/26/2023

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