Healthcare Provider Details

I. General information

NPI: 1639454168
Provider Name (Legal Business Name): KERRY VUCINOVICH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2011
Last Update Date: 10/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 DRINKWATER RD
BAY SAINT LOUIS MS
39520-1640
US

IV. Provider business mailing address

300 DRINKWATER RD
BAY SAINT LOUIS MS
39520-1640
US

V. Phone/Fax

Practice location:
  • Phone: 228-547-4727
  • Fax: 228-255-2633
Mailing address:
  • Phone: 228-547-4727
  • Fax: 228-255-2633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMS929
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA3751
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: