MEDICARE: MR. CHARLES DEMETRIUS RICE MT

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	MT.0010621	CO

General Provider Information

NPI Number	:	1801770029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES DEMETRIUS RICE MT

Provider Business Mailing Address
First Line	:	2730 VICKERS DR APT 327
Second Line	:
City	:	COLO SPGS
State	:	CO
Zip	:	80918-8919
Country	:	US
Telephone Number	:	719-464-8815
Fax Number	:

Provider Business Practice Location Address
First Line	:	304 S 8TH ST STE 103
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-1829
Country	:	US
Telephone Number	:	719-475-9103
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2025
Last Update Date	:	08/01/2025

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