MEDICARE: MRS. MICHELE MACK LMT, CPMT

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	33.02129080	OH

General Provider Information

NPI Number	:	1861893117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELE MACK LMT, CPMT

Provider Business Mailing Address
First Line	:	3850 POWDER RIDGE RD
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-1292
Country	:	US
Telephone Number	:	614-886-0290
Fax Number	:

Provider Business Practice Location Address
First Line	:	2179 STRINGTOWN RD
Second Line	:	LOFT 11
City	:	GROVE CITY
State	:	OH
Zip	:	43123-2989
Country	:	US
Telephone Number	:	614-886-0290
Fax Number	:

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

Provider Enumeration Date	:	09/05/2014
Last Update Date	:	09/05/2014

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