MEDICARE: HANNINGTON MASSAGE, LLC

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	261Q00000X	Clinic/Center	MT2398	TX

General Provider Information

NPI Number	:	1225450893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HANNINGTON MASSAGE, LLC

Provider Business Mailing Address
First Line	:	3212 COLLINSWORTH ST
Second Line	:	SUITE 14
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6580
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3212 COLLINSWORTH ST
Second Line	:	SUITE 14
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6580
Country	:	US
Telephone Number	:	817-405-9540
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	CHARLES KEZENGWA
Credential	:	LMT
Telephone Number	:	817-405-9540

Provider Enumeration Date	:	01/15/2014
Last Update Date	:	01/15/2014

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