Healthcare Provider Details

I. General information

NPI: 1053707224
Provider Name (Legal Business Name): MASSAGE CONNEXION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12603 HIGHWAY 57
VANCLEAVE MS
39565-7420
US

IV. Provider business mailing address

PO BOX 5667
VANCLEAVE MS
39565-5667
US

V. Phone/Fax

Practice location:
  • Phone: 228-283-5083
  • Fax:
Mailing address:
  • Phone: 228-283-5083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number35
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHARLENE RUSSELL
Title or Position: DIRECTOR
Credential: LMT
Phone: 228-283-5083