MEDICARE: NEURO MASSAGE THERAPIST, 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	225700000X	Massage Therapist	MM10286	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MM10286	OTHER	FL	LICENSE NUMBER

General Provider Information

NPI Number	:	1639392392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEURO MASSAGE THERAPIST, INC.

Provider Business Mailing Address
First Line	:	2295 NW CORPORATE BLVD
Second Line	:	SUITE 140
City	:	BOCA RATON
State	:	FL
Zip	:	33431-7373
Country	:	US
Telephone Number	:	561-241-1971
Fax Number	:	561-241-3969

Provider Business Practice Location Address
First Line	:	871 W OAKLAND PARK BLVD
Second Line	:	SUITE 101
City	:	WILTON MANORS
State	:	FL
Zip	:	33311-1731
Country	:	US
Telephone Number	:	954-567-5730
Fax Number	:	954-567-5731

Authorized Official
Title or Position	:	CREDENTIALING DEPT
Name	:	SUSAN SABELLA
Credential	:
Telephone Number	:	561-241-1971

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/22/2020

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