MEDICARE: MAYA'S MASSAGE INC.

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	16356	CA

General Provider Information

NPI Number	:	1558897538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYA'S MASSAGE INC.

Provider Business Mailing Address
First Line	:	860 PETALUMA BLVD N
Second Line	:	SUITE E
City	:	PETALUMA
State	:	CA
Zip	:	94952-2146
Country	:	US
Telephone Number	:	415-342-1345
Fax Number	:

Provider Business Practice Location Address
First Line	:	1955 DOGWOOD DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-1577
Country	:	US
Telephone Number	:	415-342-1345
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. MAYA NICHOLLS
Credential	:	CMT
Telephone Number	:	415-342-1345

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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