Healthcare Provider Details

I. General information

NPI: 1265354955
Provider Name (Legal Business Name): MIRAGE BODYWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 N MAIN ST
AMBLER PA
19002-5621
US

IV. Provider business mailing address

39 N MAIN ST
AMBLER PA
19002-5621
US

V. Phone/Fax

Practice location:
  • Phone: 267-210-8139
  • Fax:
Mailing address:
  • Phone: 267-210-8139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: MIRANDA BACON
Title or Position: MASSAGE THERAPIST
Credential: LMT
Phone: 267-210-8139