MEDICARE: NINA JUNE HERON LMT

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	MT000478	CO

General Provider Information

NPI Number	:	1528574704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINA JUNE HERON LMT

Provider Business Mailing Address
First Line	:	10325 COUNTY ROAD 250
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-3115
Country	:	US
Telephone Number	:	970-238-0924
Fax Number	:

Provider Business Practice Location Address
First Line	:	1032 MAIN AVE
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-5124
Country	:	US
Telephone Number	:	970-382-8332
Fax Number	:

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

Provider Enumeration Date	:	12/25/2017
Last Update Date	:	12/25/2017

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