Healthcare Provider Details

I. General information

NPI: 1649996992
Provider Name (Legal Business Name): MEAGHAN DECOSTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 ASHER CT STE 100
EAST LANSING MI
48823-8444
US

IV. Provider business mailing address

3641 BOLERO DR
EAST LANSING MI
48823-8378
US

V. Phone/Fax

Practice location:
  • Phone: 517-351-9240
  • Fax:
Mailing address:
  • Phone: 520-444-7682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501014190
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: