Healthcare Provider Details

I. General information

NPI: 1982032546
Provider Name (Legal Business Name): ESCAPE AWAY MASSAGE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 MAIN ST
NEW YORK MILLS NY
13417-1150
US

IV. Provider business mailing address

154 MAIN ST
NEW YORK MILLS NY
13417-1150
US

V. Phone/Fax

Practice location:
  • Phone: 315-269-4205
  • Fax:
Mailing address:
  • Phone: 315-269-4205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number018320
License Number StateNY

VIII. Authorized Official

Name: MRS. MELISSA TALLMAN
Title or Position: OWNER/LICENSED MASSAGE THERAPIST
Credential: LMT
Phone: 315-269-4205