MEDICARE: MEDICINE MASSAGE

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	:	1629318399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICINE MASSAGE

Provider Business Mailing Address
First Line	:	3809 ATRISCO DR NW STE C
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4902
Country	:	US
Telephone Number	:	505-615-3487
Fax Number	:	505-352-8966

Provider Business Practice Location Address
First Line	:	3809 ATRISCO DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4902
Country	:	US
Telephone Number	:	505-615-3487
Fax Number	:	505-352-8966

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER BLACK
Credential	:	LMT, MMP
Telephone Number	:	505-615-3487

Provider Enumeration Date	:	02/18/2013
Last Update Date	:	12/16/2014

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Directions to “MEDICINE MASSAGE ” Practice Location

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