MEDICARE: SANTISOUK PROUGH CMT

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	163WM1400X	Nurse Massage Therapist (NMT)	MT	AZ

General Provider Information

NPI Number	:	1306691449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANTISOUK PROUGH CMT

Provider Business Mailing Address
First Line	:	19401 N 15TH PL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-3625
Country	:	US
Telephone Number	:	510-384-5817
Fax Number	:

Provider Business Practice Location Address
First Line	:	8278 W LAKE PLEASANT PKWY
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-7441
Country	:	US
Telephone Number	:	510-384-5817
Fax Number	:

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

Provider Enumeration Date	:	04/22/2024
Last Update Date	:	02/04/2026

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Directions to “ SANTISOUK PROUGH CMT” Practice Location

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