Healthcare Provider Details

I. General information

NPI: 1164809133
Provider Name (Legal Business Name): SACRED HANDS MASSAGE & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 FRONT ST SUITE 107
WOONSOCKET RI
02895-5287
US

IV. Provider business mailing address

719 FRONT ST SUITE 107
WOONSOCKET RI
02895-5287
US

V. Phone/Fax

Practice location:
  • Phone: 401-769-4263
  • Fax: 401-921-4499
Mailing address:
  • Phone: 401-769-4263
  • Fax: 401-921-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMT01868
License Number StateRI

VIII. Authorized Official

Name: MICHAEL JAE DORVAL
Title or Position: OWNER/MASSAGE THERAPIST
Credential: LMT
Phone: 401-824-9897