Healthcare Provider Details

I. General information

NPI: 1083033799
Provider Name (Legal Business Name): GRACE BLUESTONE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 S GLENSTONE AVE SUITE M
SPRINGFIELD MO
65804-1511
US

IV. Provider business mailing address

1740 S GLENSTONE AVE SUITE M
SPRINGFIELD MO
65804
US

V. Phone/Fax

Practice location:
  • Phone: 417-886-1131
  • Fax:
Mailing address:
  • Phone: 417-886-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2010001562
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: