MEDICARE: CARROLLWOOD MASSAGE THERAPY

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	MM20152	FL

General Provider Information

NPI Number	:	1386821957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARROLLWOOD MASSAGE THERAPY

Provider Business Mailing Address
First Line	:	14465 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-2000
Country	:	US
Telephone Number	:	813-961-8177
Fax Number	:	813-961-3931

Provider Business Practice Location Address
First Line	:	14465 N DALE MABRY HWY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-2000
Country	:	US
Telephone Number	:	813-961-8177
Fax Number	:	813-961-3931

Authorized Official
Title or Position	:	BILLING REPRESENTATIVE
Name	:	DEBORAH DAVIS-HILDERLEY
Credential	:
Telephone Number	:	352-232-0470

Provider Enumeration Date	:	01/26/2008
Last Update Date	:	01/30/2008

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