Healthcare Provider Details

I. General information

NPI: 1134823685
Provider Name (Legal Business Name): MICHA WUNNER WUNNER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 MERCHANDISE DR
FORT WAYNE IN
46825-5140
US

IV. Provider business mailing address

5043 ASPEN PINE BLVD
DUBLIN OH
43016-9336
US

V. Phone/Fax

Practice location:
  • Phone: 614-285-9740
  • Fax:
Mailing address:
  • Phone: 614-285-9740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.025342
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT22007212
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: