Healthcare Provider Details

I. General information

NPI: 1760734222
Provider Name (Legal Business Name): MOBILE MASSAGE OF MICHIGAN LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8059 S PORTAGE RD
JACKSON MI
49201-8583
US

IV. Provider business mailing address

8059 S PORTAGE RD
JACKSON MI
49201-8583
US

V. Phone/Fax

Practice location:
  • Phone: 517-937-7961
  • Fax:
Mailing address:
  • Phone: 517-937-7961
  • 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: MR. WAYNE MAX GOODING
Title or Position: OWNER
Credential: C.M.T.
Phone: 517-937-7961