MEDICARE: JACK MAGBANUA WOLFE 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	MT.0028072	CO

General Provider Information

NPI Number	:	1750231445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK MAGBANUA WOLFE LMT

Provider Business Mailing Address
First Line	:	3992 RIVIERA GRV APT 101
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-3379
Country	:	US
Telephone Number	:	719-200-7590
Fax Number	:

Provider Business Practice Location Address
First Line	:	2320 W COLORADO AVE STE 115
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80904-3354
Country	:	US
Telephone Number	:	719-200-7590
Fax Number	:

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

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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