Healthcare Provider Details

I. General information

NPI: 1457092090
Provider Name (Legal Business Name): MINDY'S MASSAGE AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 W TOWN PL STE 22
ST AUGUSTINE FL
32092-3103
US

IV. Provider business mailing address

319 W TOWN PL STE 22
ST AUGUSTINE FL
32092-3103
US

V. Phone/Fax

Practice location:
  • Phone: 904-680-7328
  • Fax:
Mailing address:
  • Phone: 904-680-7328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: MINDY LYNN MILTON
Title or Position: PRESIDENT/OWNER
Credential: LMT
Phone: 904-680-7328