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General NPI Number Information
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NPI Number | 1003295312
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Entity Type | Organization
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Legal Business Name | PEACOCK HEAVENLY MASSAGE
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Dates
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Enumeration Date | 05/20/2015
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Last Update Date | 05/20/2015
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Provider Practice Location Address
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Address Line | 3800 HWY 365 REGIONAL SQUARE
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City | PORT ARTHUR
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State | TX
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Zip | 77642
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Country | US
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Telephone | 409-724-7882
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Fax |
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Provider Business Mailing Address
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Address Line | 3800 HWY 365, SUITE 159
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City | PORT ARTHUR
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State | TX
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Zip | 77642
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Country | US
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Telephone | 409-724-7882
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Fax | 409-853-1777
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Authorized Official
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Title or Position | LIS. MASSAGE THERAPIST
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Name | MRS. LUCY MAE PEACOCK
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Credential | LMT
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Telephone | 409-724-7882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT034536
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License Number State | TX
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