Healthcare Provider Details

I. General information

NPI: 1376668087
Provider Name (Legal Business Name): MELISSA DALE HALL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 OLD MOULTRIE RD 107
ST AUGUSTINE FL
32086-5102
US

IV. Provider business mailing address

2945 KINGS RD LOT B
ST AUGUSTINE FL
32086-5467
US

V. Phone/Fax

Practice location:
  • Phone: 904-501-5974
  • Fax:
Mailing address:
  • Phone: 904-501-5974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA22809
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: