MEDICARE: THERAPEUTIC AND SPORTS MASSAGE INC

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	MA5866	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C5493	OTHER	FL	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1770660474
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPEUTIC AND SPORTS MASSAGE INC

Provider Business Mailing Address
First Line	:	2821 E COMMERCIAL BLVD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4216
Country	:	US
Telephone Number	:	954-776-1902
Fax Number	:	954-776-9130

Provider Business Practice Location Address
First Line	:	2821 E COMMERCIAL BLVD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4216
Country	:	US
Telephone Number	:	954-776-1902
Fax Number	:	954-776-9130

Authorized Official
Title or Position	:	OWNER THERAPIST
Name	:	MR. STEPHEN R SMITH
Credential	:	LMT
Telephone Number	:	954-776-1902

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/22/2020

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