MEDICARE: QUALITY THERAPEUTIC MASSAGE 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	174400000X	Specialist

General Provider Information

NPI Number	:	1376013813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUALITY THERAPEUTIC MASSAGE LLC

Provider Business Mailing Address
First Line	:	PO BOX 115294
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310
Country	:	US
Telephone Number	:	678-612-1051
Fax Number	:

Provider Business Practice Location Address
First Line	:	423 TAZOR ST NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30314-2718
Country	:	US
Telephone Number	:	678-612-1051
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MASSAGE THERAPIST
Name	:	MS. STACY GLINTON
Credential	:	LMT
Telephone Number	:	678-612-1051

Provider Enumeration Date	:	11/27/2018
Last Update Date	:	11/27/2018

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