Healthcare Provider Details

I. General information

NPI: 1376755918
Provider Name (Legal Business Name): MIRACLE SALON & SPA DBA NATURAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6632 SUMMERFIELD RD
TEMPERANCE MI
48182-1339
US

IV. Provider business mailing address

6632 SUMMERFIELD RD
TEMPERANCE MI
48182-1339
US

V. Phone/Fax

Practice location:
  • Phone: 734-850-9355
  • Fax: 734-850-9356
Mailing address:
  • Phone: 734-850-9355
  • Fax: 734-850-9356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number10293
License Number StateOH

VIII. Authorized Official

Name: MR. MICHAEL HOLLERBACH
Title or Position: CLINICAL DIRECTOR
Credential: LMT
Phone: 734-850-9355