MEDICARE: MOUNTAINSIDE DIVERSIFIED

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	:	1689251712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAINSIDE DIVERSIFIED

Provider Business Mailing Address
First Line	:	PO BOX 20521
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-0521
Country	:	US
Telephone Number	:	877-480-8038
Fax Number	:

Provider Business Practice Location Address
First Line	:	1324 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2044
Country	:	US
Telephone Number	:	877-480-8038
Fax Number	:

Authorized Official
Title or Position	:	PARTNER/MANAGER
Name	:	HEATHER MILLER
Credential	:	LMT, BCTMB
Telephone Number	:	877-480-8038

Provider Enumeration Date	:	03/25/2021
Last Update Date	:	03/25/2021

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Directions to “MOUNTAINSIDE DIVERSIFIED ” Practice Location

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