MEDICARE: SERITA BOSTICK 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	0019010291	VA

General Provider Information

NPI Number	:	1346843026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERITA BOSTICK LMT

Provider Business Mailing Address
First Line	:	3300 GWIN ST
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-6019
Country	:	US
Telephone Number	:	757-449-0178
Fax Number	:

Provider Business Practice Location Address
First Line	:	4605 PEMBROKE LAKE CIR STE 303
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-6448
Country	:	US
Telephone Number	:	757-449-0178
Fax Number	:

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

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	01/02/2023

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