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NPI Code Detail

MEDICARE: VITAL LIVING THERAPEUTIC MASSAGE, LLC

MEDICARE: VITAL LIVING THERAPEUTIC MASSAGE, 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
1225700000XMassage TherapistMT20901877IN
2163WM1400XNurse Massage Therapist (NMT)28057959AIN

General Provider Information

NPI Number : 1790151157
Entity Type Code : Organization
Provider Name (Legal Business Name) : VITAL LIVING THERAPEUTIC MASSAGE, LLC
Provider Business Mailing Address
First Line : 5111 N BEND DR
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-1753
Country : US
Telephone Number : 260-436-8807
Fax Number : 260-436-2767
Provider Business Practice Location Address
First Line : 5111 N BEND DR
Second Line :
City : FORT WAYNE
State : IN
Zip : 46804-1753
Country : US
Telephone Number : 260-436-8807
Fax Number : 260-436-2767
Authorized Official
Title or Position : OWNER
Name : JANET CARROLL
Credential :
Telephone Number : 260-436-8807
Provider Enumeration Date : 08/19/2015
Last Update Date : 08/19/2015

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Directions to “VITAL LIVING THERAPEUTIC MASSAGE, LLC ” Practice Location

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