MEDICARE: SOMA HEALING MASSAGE THERAPY, LLC

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	302R00000X	Health Maintenance Organization	10824	CO

General Provider Information

NPI Number	:	1669852554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOMA HEALING MASSAGE THERAPY, LLC

Provider Business Mailing Address
First Line	:	1892 MALLARD DR
Second Line	:
City	:	SUPERIOR
State	:	CO
Zip	:	80027-4434
Country	:	US
Telephone Number	:	720-840-3650
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 W SOUTH BOULDER RD
Second Line	:	SUITE 209
City	:	LOUISVILLE
State	:	CO
Zip	:	80027-1156
Country	:	US
Telephone Number	:	720-840-3650
Fax Number	:

Authorized Official
Title or Position	:	SPORTS/ORTHOPEDIC MASSAGE THERAPIST
Name	:	ELIZABETH CARD
Credential	:	RMT
Telephone Number	:	720-840-3650

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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