Healthcare Provider Details

I. General information

NPI: 1578913067
Provider Name (Legal Business Name): MYO-MY MASSAGE AND FITNESS CAFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12075 HAVANA RD
GARFIELD HEIGHTS OH
44125-4508
US

IV. Provider business mailing address

1803 TAMARRON PKWY SE
ATLANTA GA
30339-6714
US

V. Phone/Fax

Practice location:
  • Phone: 770-906-5271
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY MCCANTS
Title or Position: CEO
Credential:
Phone: 770-906-5271