MEDICARE: MS. MUZIQUE LATISE BROADNAX CMT, MMP,LMT,CA

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	175L00000X	Homeopath	938479	MN
2	225700000X	Massage Therapist	MT-27885	AZ

General Provider Information

NPI Number	:	1285935726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MUZIQUE LATISE BROADNAX CMT, MMP,LMT,CA

Provider Business Mailing Address
First Line	:	4600 E WASHINGTON ST STE 300
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85034-1908
Country	:	US
Telephone Number	:	612-486-2775
Fax Number	:

Provider Business Practice Location Address
First Line	:	2915 WAYZATA BLVD
Second Line	:	304
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2145
Country	:	US
Telephone Number	:	612-396-2016
Fax Number	:

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

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	09/29/2021

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