MEDICARE: TABLE FOR ONE MASSAGE THERAPY

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	251J00000X	Nursing Care Agency	C20010018	MI

General Provider Information

NPI Number	:	1699213058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TABLE FOR ONE MASSAGE THERAPY

Provider Business Mailing Address
First Line	:	412 MICHIGAN AVENUE
Second Line	:
City	:	CRYSTAL FALLS
State	:	MI
Zip	:	49920
Country	:	US
Telephone Number	:	906-367-2060
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 MICHIGAN AVE
Second Line	:
City	:	CRYSTAL FALLS
State	:	MI
Zip	:	49920-1416
Country	:	US
Telephone Number	:	906-367-2060
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MASSAGE THERAPIST
Name	:	MISS TINA MARIE ST JOHN
Credential	:	RN LMT
Telephone Number	:	906-367-2060

Provider Enumeration Date	:	02/06/2017
Last Update Date	:	02/06/2017

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