Healthcare Provider Details

I. General information

NPI: 1699595256
Provider Name (Legal Business Name): PAMELA VACAOLIVO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 06/01/2025
Certification Date: 06/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 FLAT SHOALS RD SE
CONYERS GA
30094-5911
US

IV. Provider business mailing address

200 TRAVIS DR UNIT 1105
MCDONOUGH GA
30252-2935
US

V. Phone/Fax

Practice location:
  • Phone: 678-468-5793
  • Fax: 207-613-2777
Mailing address:
  • Phone: 678-468-5793
  • Fax: 207-613-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT014014
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: