Healthcare Provider Details

I. General information

NPI: 1164707832
Provider Name (Legal Business Name): MIRACLE MASSAGE AND REHAB CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 E 9TH ST
HIALEAH FL
33010-4552
US

IV. Provider business mailing address

624 E 9TH ST
HIALEAH FL
33010-4552
US

V. Phone/Fax

Practice location:
  • Phone: 305-887-8701
  • Fax: 305-887-8705
Mailing address:
  • Phone: 305-887-8701
  • Fax: 305-887-8705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMA 61548
License Number StateFL

VIII. Authorized Official

Name: ANYELEY MESA
Title or Position: OWNER
Credential: MA 61548
Phone: 305-887-8701