MEDICARE: COAST TO COAST MASSAGE THERAPY BY JEREMY MINNICK INC.

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	MA25921	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C3738	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1356696934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COAST TO COAST MASSAGE THERAPY BY JEREMY MINNICK INC.

Provider Business Mailing Address
First Line	:	2143 NW 17TH AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-3101
Country	:	US
Telephone Number	:	239-671-9900
Fax Number	:

Provider Business Practice Location Address
First Line	:	2143 NW 17TH AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33993-3101
Country	:	US
Telephone Number	:	239-671-9900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT / OWNER
Name	:	MR. JEREMY A MINNICK
Credential	:	LMT
Telephone Number	:	239-671-9900

Provider Enumeration Date	:	07/19/2012
Last Update Date	:	07/19/2012

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