Healthcare Provider Details

I. General information

NPI: 1982432126
Provider Name (Legal Business Name): INNER HEALTH SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1733 S 5TH ST
SPRINGFIELD IL
62703-3116
US

IV. Provider business mailing address

1733 S 5TH ST
SPRINGFIELD IL
62703-3116
US

V. Phone/Fax

Practice location:
  • Phone: 217-572-1611
  • Fax:
Mailing address:
  • Phone: 217-572-1611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHELLE ANN BULLOCK
Title or Position: OWNER/MASSAGE THERAPIST
Credential: LMT
Phone: 217-572-1611