Healthcare Provider Details

I. General information

NPI: 1922911148
Provider Name (Legal Business Name): MICHAEL GRACE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 ROANOKE BLVD STE 2
SALEM VA
24153-5033
US

IV. Provider business mailing address

954 ROANOKE BLVD
SALEM VA
24153-5209
US

V. Phone/Fax

Practice location:
  • Phone: 540-328-5858
  • Fax:
Mailing address:
  • Phone: 540-328-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0019002362
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: