MEDICARE: MR. JASON CHARLES LMT, LMBT

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	18KT00810300	NJ
2	225700000X	Massage Therapist	030754	NY

General Provider Information

NPI Number	:	1457707226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON CHARLES LMT, LMBT

Provider Business Mailing Address
First Line	:	1324 FOREST AVE
Second Line	:	STE 125
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2044
Country	:	US
Telephone Number	:	646-838-1729
Fax Number	:

Provider Business Practice Location Address
First Line	:	1324 FOREST AVE
Second Line	:	STE 125
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2044
Country	:	US
Telephone Number	:	646-838-1729
Fax Number	:

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

Provider Enumeration Date	:	05/10/2016
Last Update Date	:	10/21/2017

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