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General NPI Number Information
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NPI Number | 1154099570
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Entity Type | Organization
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Legal Business Name | EAST END SPORTS MASSAGE
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Dates
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Enumeration Date | 08/31/2021
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Last Update Date | 08/31/2021
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Provider Practice Location Address
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Address Line | 222 MANOR PL STE 7
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City | GREENPORT
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State | NY
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Zip | 11944-1261
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Country | US
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Telephone | 631-268-4769
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Fax |
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Provider Business Mailing Address
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Address Line | 2595 VILLAGE LN
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City | ORIENT
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State | NY
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Zip | 11957-1469
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Country | US
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Telephone | 718-683-1905
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NICOLE KENNELLY
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Credential | LMT
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Telephone | 718-683-1905
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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 |
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License Number State |
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