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General NPI Number Information
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NPI Number | 1104253285
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Entity Type | Organization
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Legal Business Name | MASSAGE REVOLUTION
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Dates
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Enumeration Date | 10/03/2013
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Last Update Date | 10/03/2013
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Provider Practice Location Address
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Address Line | 210 E CAPITOL ST SUITE M-142
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City | JACKSON
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State | MS
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Zip | 39201-2306
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Country | US
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Telephone | 601-918-1853
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Fax |
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Provider Business Mailing Address
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Address Line | 210 E CAPITOL ST SUITE M-142
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City | JACKSON
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State | MS
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Zip | 39201-2306
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Country | US
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Telephone | 601-918-1853
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Fax |
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | MR. ABRAHAM SANTA CRUZ
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Credential |
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Telephone | 601-918-1853
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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 | 2027
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License Number State | MS
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