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General NPI Number Information
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NPI Number | 1194105247
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Entity Type | Organization
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Legal Business Name | NEW RIVER MEDICCAL MASSAGE
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Dates
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Enumeration Date | 06/04/2015
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Last Update Date | 06/04/2015
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Provider Practice Location Address
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Address Line | 319 W MAIN ST
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City | RADFORD
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State | VA
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Zip | 24141-1586
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Country | US
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Telephone | 540-633-3828
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Fax | 540-633-3829
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Provider Business Mailing Address
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Address Line | 319 WEST MAIN STREET
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City | RADFORD
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State | VA
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Zip | 24301
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Country | US
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Telephone | 540-633-3828
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Fax | 540-633-3829
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | MR. ROBERT ERNEST WALLACE
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Credential | MASSAGE THERAPIST
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Telephone | 540-633-3828
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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 | 0019001695
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License Number State | VA
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