MEDICARE: EMMANUEL BISTAS LMT

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	227001888	IL

General Provider Information

NPI Number	:	1861243206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMANUEL BISTAS LMT

Provider Business Mailing Address
First Line	:	21385 GEORGETOWN RD
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-3009
Country	:	US
Telephone Number	:	312-493-1840
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 E HURON ST STE 200
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-5244
Country	:	US
Telephone Number	:	312-493-1840
Fax Number	:

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

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	04/01/2024

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