Healthcare Provider Details

I. General information

NPI: 1881067627
Provider Name (Legal Business Name): LIVING YOUNGER MOVMENT THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S POWER RD
MESA AZ
85206-5235
US

IV. Provider business mailing address

508 N MERRILL RD
MESA AZ
85207-2423
US

V. Phone/Fax

Practice location:
  • Phone: 602-821-5008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20939
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20953
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number8439
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number8479
License Number StateAZ

VIII. Authorized Official

Name: MRS. LAURA LAMB
Title or Position: OWNER
Credential: BS, LMT
Phone: 602-821-5008