MEDICARE: KITSAP THERAPEUTIC MEDICAL MASSAGE AND BODYWORK, 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	225700000X	Massage Therapist	MA000020549	WA

General Provider Information

NPI Number	:	1326346768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KITSAP THERAPEUTIC MEDICAL MASSAGE AND BODYWORK, LLC

Provider Business Mailing Address
First Line	:	PO BOX 4988
Second Line	:
City	:	SOUTH COLBY
State	:	WA
Zip	:	98384-0988
Country	:	US
Telephone Number	:	360-710-8097
Fax Number	:

Provider Business Practice Location Address
First Line	:	4275 SE MILE HILL DR
Second Line	:	SUITE B
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-3934
Country	:	US
Telephone Number	:	360-710-3299
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JULENE NIKOLAC
Credential	:	LMP
Telephone Number	:	360-710-3299

Provider Enumeration Date	:	03/09/2011
Last Update Date	:	11/14/2016

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