Healthcare Provider Details

I. General information

NPI: 1346797495
Provider Name (Legal Business Name): GO MADD 4 MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 US HIGHWAY 1 S STE 7
ST AUGUSTINE FL
32086-6193
US

IV. Provider business mailing address

2600 US HIGHWAY 1 S STE 7
ST AUGUSTINE FL
32086-6193
US

V. Phone/Fax

Practice location:
  • Phone: 904-708-1083
  • Fax:
Mailing address:
  • Phone: 904-708-1083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMM16790
License Number StateFL

VIII. Authorized Official

Name: DIANA CAROL BERANEK
Title or Position: OWNER
Credential:
Phone: 904-708-1083