Healthcare Provider Details

I. General information

NPI: 1962643072
Provider Name (Legal Business Name): MY MASSAGE SANCTUARY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NORTH ALPINE ROAD
ROCKFORD IL
61107
US

IV. Provider business mailing address

101 NORTH ALPINE ROAD
ROCKFORD IL
61107
US

V. Phone/Fax

Practice location:
  • Phone: 779-423-1700
  • Fax: 866-596-1027
Mailing address:
  • Phone: 779-423-1700
  • Fax: 866-596-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number227.003938
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number198.000709
License Number StateIL

VIII. Authorized Official

Name: LEILA I KAYSER
Title or Position: CEO
Credential: CEO
Phone: 815-301-7809