MEDICARE: ANGELIQUE LYNETTE SLATER 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	33.024054	OH

General Provider Information

NPI Number	:	1720791445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELIQUE LYNETTE SLATER LMT

Provider Business Mailing Address
First Line	:	5345 GERMANTOWN PIKE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-6220
Country	:	US
Telephone Number	:	937-276-2664
Fax Number	:

Provider Business Practice Location Address
First Line	:	4479 FAR HILLS AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-2405
Country	:	US
Telephone Number	:	937-367-3420
Fax Number	:

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

Provider Enumeration Date	:	12/27/2022
Last Update Date	:	12/27/2022

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