MEDICARE: SKIN REVIVE MASSAGE AND SPA, 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

General Provider Information

NPI Number	:	1427757723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SKIN REVIVE MASSAGE AND SPA, LLC

Provider Business Mailing Address
First Line	:	13453 N MAIN ST STE 304
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-2273
Country	:	US
Telephone Number	:	904-955-2706
Fax Number	:

Provider Business Practice Location Address
First Line	:	13453 N MAIN ST STE 304
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-2273
Country	:	US
Telephone Number	:	904-955-2706
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MASSAGE THERAPIST/OWNER
Name	:	TARA LESTER
Credential	:	LMT
Telephone Number	:	904-955-2706

Provider Enumeration Date	:	02/27/2023
Last Update Date	:	02/27/2023

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