Healthcare Provider Details

I. General information

NPI: 1578907663
Provider Name (Legal Business Name): SILVER DOOR SPA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 04/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 S RANGELINE RD
CARMEL IN
46032-3035
US

IV. Provider business mailing address

762 S RANGELINE RD
CARMEL IN
46032-3035
US

V. Phone/Fax

Practice location:
  • Phone: 317-816-7587
  • Fax:
Mailing address:
  • Phone: 317-816-7587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: CORTNEY REISELMAN
Title or Position: PRESIDENT
Credential:
Phone: 614-571-2901