MEDICARE: ERIN BERNICE LEGROS MASSAGE THERAPIST

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	173C00000X	Reflexologist	MT20903164	IN
2	174H00000X	Health Educator	MT20903164	IN
3	225700000X	Massage Therapist	MT20903164	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MT20903164	OTHER	IN	INDIANA PROFESSIONAL LICENSING AGENCY

General Provider Information

NPI Number	:	1215258264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN BERNICE LEGROS MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	622 W 39TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-3929
Country	:	US
Telephone Number	:	317-921-0972
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 E 52ND ST
Second Line	:	SUITE 12
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1172
Country	:	US
Telephone Number	:	317-921-0972
Fax Number	:

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

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	06/14/2010

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