Healthcare Provider Details

I. General information

NPI: 1013755719
Provider Name (Legal Business Name): MASSAGE TRINITY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 CHESTER CIR STE 206
JACKSONVILLE FL
32217-2273
US

IV. Provider business mailing address

6015 CHESTER CIR STE 206
JACKSONVILLE FL
32217-2273
US

V. Phone/Fax

Practice location:
  • Phone: 904-365-8305
  • Fax: 904-365-8198
Mailing address:
  • Phone: 904-412-6415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. NICOLE SMITH
Title or Position: PRESIDENT/CEO
Credential:
Phone: 904-365-8305