MEDICARE: FOOTPRINTS ON THE MOON MASSAGE AND BODYWORK, LLC

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	MM32405	FL

General Provider Information

NPI Number	:	1760898506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTPRINTS ON THE MOON MASSAGE AND BODYWORK, LLC

Provider Business Mailing Address
First Line	:	1312 ILLINOIS AVE
Second Line	:	SUITE E
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-4506
Country	:	US
Telephone Number	:	407-436-2122
Fax Number	:

Provider Business Practice Location Address
First Line	:	1312 ILLINOIS AVE
Second Line	:	SUITE E
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-4506
Country	:	US
Telephone Number	:	407-436-2122
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	SAMANTHA JO FAGNANT
Credential	:	LMT
Telephone Number	:	407-436-2122

Provider Enumeration Date	:	07/01/2014
Last Update Date	:	07/01/2014

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