Provider Demographics
NPI:1639666506
Name:MEDSPORT MASSAGE, LLC
Entity Type:Organization
Organization Name:MEDSPORT MASSAGE, LLC
Other - Org Name:SUSAN M PETERS, SOLE MBR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER OF MEDSPORT MASSAGE
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED MASSAGE THE
Authorized Official - Phone:207-807-7465
Mailing Address - Street 1:MEDSPORT MASSAGE
Mailing Address - Street 2:PO BOX 74
Mailing Address - City:NEW CASTLE
Mailing Address - State:ME
Mailing Address - Zip Code:04553-0074
Mailing Address - Country:US
Mailing Address - Phone:207-807-7465
Mailing Address - Fax:207-882-7439
Practice Address - Street 1:39 RIVER ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW CASTLE
Practice Address - State:ME
Practice Address - Zip Code:04553-0074
Practice Address - Country:US
Practice Address - Phone:207-807-7465
Practice Address - Fax:207-882-7439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT4833225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty