MEDICARE: OLENA FOSFOROVA LMBT

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	12549	NC

General Provider Information

NPI Number	:	1891222303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLENA FOSFOROVA LMBT

Provider Business Mailing Address
First Line	:	1100 S MINT ST STE 109
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-4058
Country	:	US
Telephone Number	:	704-763-9044
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 S MINT ST STE 109
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-4058
Country	:	US
Telephone Number	:	704-763-9044
Fax Number	:

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

Provider Enumeration Date	:	05/15/2017
Last Update Date	:	07/21/2022

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Directions to “ OLENA FOSFOROVA LMBT” Practice Location

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