Healthcare Provider Details

I. General information

NPI: 1245695360
Provider Name (Legal Business Name): JENNIFER MOURGAS L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2283 GRAND ISLAND BLVD
GRAND ISLAND NY
14072-1819
US

IV. Provider business mailing address

2283 GRAND ISLAND BLVD
GRAND ISLAND NY
14072-1819
US

V. Phone/Fax

Practice location:
  • Phone: 716-773-2222
  • Fax:
Mailing address:
  • Phone: 716-773-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number009111-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: