MEDICARE: SIMPLE MASSAAGE, 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	MT08021	AZ

General Provider Information

NPI Number	:	1770969032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMPLE MASSAAGE, LLC

Provider Business Mailing Address
First Line	:	3709 N 9TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-5015
Country	:	US
Telephone Number	:	480-525-7322
Fax Number	:

Provider Business Practice Location Address
First Line	:	3709 N 9TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-5015
Country	:	US
Telephone Number	:	480-525-7322
Fax Number	:

Authorized Official
Title or Position	:	MASSAGE THERAPIST
Name	:	MR. JOSHUA SCOFIELD
Credential	:	LMT
Telephone Number	:	480-525-7322

Provider Enumeration Date	:	08/09/2015
Last Update Date	:	09/22/2015

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