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General NPI Number Information
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NPI Number | 1265354955
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Entity Type | Organization
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Legal Business Name | MIRAGE BODYWORK LLC
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Dates
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Enumeration Date | 07/27/2026
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Last Update Date | 07/27/2026
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Provider Practice Location Address
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Address Line | 39 N MAIN ST
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City | AMBLER
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State | PA
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Zip | 19002-5621
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Country | US
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Telephone | 267-210-8139
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Fax |
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Provider Business Mailing Address
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Address Line | 39 N MAIN ST
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City | AMBLER
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State | PA
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Zip | 19002-5621
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Country | US
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Telephone | 267-210-8139
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Fax |
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Authorized Official
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Title or Position | MASSAGE THERAPIST
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Name | MIRANDA BACON
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Credential | LMT
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Telephone | 267-210-8139
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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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