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General NPI Number Information
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NPI Number | 1174820633
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Entity Type | Organization
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Legal Business Name | THREE PATHS MASSAGE THERAPY
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Dates
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Enumeration Date | 02/18/2011
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Last Update Date | 02/18/2011
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Provider Practice Location Address
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Address Line | 5901 N PROSPECT RD STE 102
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City | PEORIA
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State | IL
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Zip | 61614-4395
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Country | US
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Telephone | 309-839-2004
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Fax |
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Provider Business Mailing Address
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Address Line | 5901 N PROSPECT RD STE 102
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City | PEORIA
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State | IL
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Zip | 61614-4395
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Country | US
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Telephone | 309-839-2004
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AME NGUYEN
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Credential | LMT
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Telephone | 309-839-2004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 227000906
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License Number State | IL
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