MEDICARE: MR. STEPHEN WADE 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	2390	AL

General Provider Information

NPI Number	:	1255939039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN WADE LMT

Provider Business Mailing Address
First Line	:	1301 27TH PL S APT 5
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35205-2542
Country	:	US
Telephone Number	:	205-792-1967
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 OFFICE PARK CIR STE 12C
Second Line	:
City	:	MOUNTAIN BRK
State	:	AL
Zip	:	35223-2923
Country	:	US
Telephone Number	:	205-792-1967
Fax Number	:

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

Provider Enumeration Date	:	10/13/2020
Last Update Date	:	10/13/2020

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