MEDICARE: MYO-MY MASSAGE AND FITNESS CAFE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	171000000X	Military Health Care Provider
2	251K00000X	Public Health or Welfare Agency
3	305S00000X	Point of Service
4	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1578913067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYO-MY MASSAGE AND FITNESS CAFE, LLC

Provider Business Mailing Address
First Line	:	1803 TAMARRON PKWY SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-6714
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12075 HAVANA RD
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-4508
Country	:	US
Telephone Number	:	770-906-5271
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KIMBERLY MCCANTS
Credential	:
Telephone Number	:	770-906-5271

Provider Enumeration Date	:	06/15/2016
Last Update Date	:	06/15/2016

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