MEDICARE: HOLLY BOSTON LMT

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	101667	AK

General Provider Information

NPI Number	:	1699390971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY BOSTON LMT

Provider Business Mailing Address
First Line	:	110 W TUDOR RD STE D
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99503-7247
Country	:	US
Telephone Number	:	907-830-0266
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 W TUDOR RD STE D
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99503-7247
Country	:	US
Telephone Number	:	907-830-0266
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2020
Last Update Date	:	06/11/2020

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Directions to “ HOLLY BOSTON LMT” Practice Location

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