Healthcare Provider Details

I. General information

NPI: 1396120598
Provider Name (Legal Business Name): MASSAGE ON DA GO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 ROSEMARY DR APT 4
SOUTHAVEN MS
38671-3977
US

IV. Provider business mailing address

199 ROSEMARY DR APT 4
SOUTHAVEN MS
38671-3977
US

V. Phone/Fax

Practice location:
  • Phone: 901-591-6485
  • Fax:
Mailing address:
  • Phone: 901-591-6485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2038
License Number StateMS

VIII. Authorized Official

Name: SHAWANDA EUNICE CHANEY
Title or Position: OWNER
Credential:
Phone: 901-591-6485