MEDICARE: MS. HOLLY LODGE 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

General Provider Information

NPI Number	:	1962670281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HOLLY LODGE MT

Provider Business Mailing Address
First Line	:	3413 EDGEWOOD ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-4167
Country	:	US
Telephone Number	:	313-930-9139
Fax Number	:

Provider Business Practice Location Address
First Line	:	3413 EDGEWOOD ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-4167
Country	:	US
Telephone Number	:	313-930-9139
Fax Number	:

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

Provider Enumeration Date	:	02/20/2008
Last Update Date	:	02/20/2008

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