Healthcare Provider Details

I. General information

NPI: 1649461641
Provider Name (Legal Business Name): GREENWAY MASSAGE TEAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E WALNUT ST
COLUMBIA MO
65201-4863
US

IV. Provider business mailing address

810 E WALNUT ST
COLUMBIA MO
65201-4863
US

V. Phone/Fax

Practice location:
  • Phone: 573-449-4929
  • Fax: 573-449-4933
Mailing address:
  • Phone: 573-449-4929
  • Fax: 573-449-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2006005578
License Number StateMO

VIII. Authorized Official

Name: MIRRA GREEMWAY
Title or Position: OWNER
Credential: LMT, NCBTMB
Phone: 573-449-4929