Healthcare Provider Details

I. General information

NPI: 1770061616
Provider Name (Legal Business Name): BLU MAGNOLIA WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 W LAUREL AVE
EUNICE LA
70535-2905
US

IV. Provider business mailing address

4263 CHATAIGNIER RD
VILLE PLATTE LA
70586-6848
US

V. Phone/Fax

Practice location:
  • Phone: 337-580-8150
  • Fax:
Mailing address:
  • Phone: 337-580-8150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8832
License Number StateLA

VIII. Authorized Official

Name: ASHLEY NICHOLS-HOPKINS
Title or Position: OWNER
Credential: LMT
Phone: 337-580-8150