Healthcare Provider Details

I. General information

NPI: 1760870224
Provider Name (Legal Business Name): AMANDAS MINI DAY SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E CHAIN OF ROCKS RD
GRANITE CITY IL
62040-2803
US

IV. Provider business mailing address

510 E CHAIN OF ROCKS RD
GRANITE CITY IL
62040-2803
US

V. Phone/Fax

Practice location:
  • Phone: 314-467-0766
  • Fax:
Mailing address:
  • Phone: 314-467-0766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2001010642
License Number StateMO

VIII. Authorized Official

Name: MS. AMANDA RANSOM
Title or Position: OWNER
Credential: LMT
Phone: 314-467-0766