Healthcare Provider Details

I. General information

NPI: 1558659920
Provider Name (Legal Business Name): MASSAGE HEIGHTS SHOAL CREEK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9225 NE 152 HWY
LIBERTY MO
64158
US

IV. Provider business mailing address

9225 NE 152 HWY
LIBERTY MO
64158
US

V. Phone/Fax

Practice location:
  • Phone: 816-792-4783
  • Fax: 816-792-4957
Mailing address:
  • Phone: 816-792-4783
  • Fax: 816-792-4957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2007037586
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2007037586
License Number StateMO

VIII. Authorized Official

Name: TOM DUSTERHOFT
Title or Position: OWNER
Credential:
Phone: 816-792-4783