Healthcare Provider Details

I. General information

NPI: 1669503199
Provider Name (Legal Business Name): ALBANY THERAPEUTIC MASSAGE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 DAWSON RD
ALBANY GA
31707
US

IV. Provider business mailing address

1534 DAWSON RD
ALBANY GA
31707
US

V. Phone/Fax

Practice location:
  • Phone: 229-435-9008
  • Fax: 229-435-9080
Mailing address:
  • Phone: 229-435-9008
  • Fax: 229-435-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA10936
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT000009
License Number StateGA

VIII. Authorized Official

Name: MS. VIVIAN L DAVIS
Title or Position: PRES
Credential: MASSAGE THERAPIST
Phone: 229-435-9008