MEDICARE: CAROLINA MASSAGE THERAPY

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	:	1215459250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA MASSAGE THERAPY

Provider Business Mailing Address
First Line	:	2006 S MAIN ST STE 206
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-9391
Country	:	US
Telephone Number	:	919-570-6556
Fax Number	:	919-882-1141

Provider Business Practice Location Address
First Line	:	2006 S MAIN ST STE 206
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-9391
Country	:	US
Telephone Number	:	919-570-6556
Fax Number	:	919-882-1141

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	JILL GRANTHAM
Credential	:
Telephone Number	:	919-570-6556

Provider Enumeration Date	:	07/12/2017
Last Update Date	:	07/12/2017

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Directions to “CAROLINA MASSAGE THERAPY ” Practice Location

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