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General NPI Number Information
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NPI Number | 1104356591
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Entity Type | Organization
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Legal Business Name | LAKEWOOD RANCH MEDICAL MASSAGE, LLC
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Dates
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Enumeration Date | 06/18/2017
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Last Update Date | 06/18/2017
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Provider Practice Location Address
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Address Line | 9070 58TH DR E STE 102
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City | BRADENTON
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State | FL
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Zip | 34202-6110
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Country | US
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Telephone | 941-321-5311
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Fax | 941-321-5311
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Provider Business Mailing Address
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Address Line | 11161 E STATE ROAD 70 STE 110-360
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City | LAKEWOOD RANCH
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State | FL
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Zip | 34202-9407
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Country | US
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Telephone | 941-321-5311
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Fax |
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Authorized Official
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Title or Position | OWNER / THERAPIST
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Name | ELIZABETH NICOLE PUGH
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Credential | LMT
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Telephone | 941-321-5311
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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 | MA40424
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License Number State | FL
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