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General NPI Number Information
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NPI Number | 1194982140
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Entity Type | Organization
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Legal Business Name | EDEN MASSAGE & SPA, INC
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Dates
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Enumeration Date | 05/19/2008
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Last Update Date | 05/19/2008
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Provider Practice Location Address
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Address Line | 2655 E OAKLAND PARK BLVD SUITE #2
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City | FORT LAUDERDALE
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State | FL
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Zip | 33306-1608
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Country | US
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Telephone | 954-564-9536
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Fax | 954-565-2910
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Provider Business Mailing Address
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Address Line | 2655 E OAKLAND PARK BLVD SUITE #2
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City | FORT LAUDERDALE
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State | FL
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Zip | 33306-1608
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Country | US
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Telephone | 954-564-9536
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Fax | 954-565-2910
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MS. GRACE OKON PAUL
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Credential | LMT
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Telephone | 954-564-9536
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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 | LIC #19555
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License Number State | FL
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