MEDICARE: AVALON MASSAGE & BODY WORKS 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	MM25438	FL

General Provider Information

NPI Number	:	1780980722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVALON MASSAGE & BODY WORKS INC.

Provider Business Mailing Address
First Line	:	430 SUMMERHAVEN DR
Second Line	:	300
City	:	DEBARY
State	:	FL
Zip	:	32713-2755
Country	:	US
Telephone Number	:	386-848-0548
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 SUMMERHAVEN DR
Second Line	:	300
City	:	DEBARY
State	:	FL
Zip	:	32713-2755
Country	:	US
Telephone Number	:	386-848-0548
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	TERESA MILLER
Credential	:
Telephone Number	:	386-848-0548

Provider Enumeration Date	:	02/09/2011
Last Update Date	:	05/05/2011

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