=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285475061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIMOSAS N MASSAGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2024
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6060 SUNRISE VISTA DR STE 2180
-----------------------------------------------------
City | CITRUS HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95610-7057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-548-6018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6060 SUNRISE VISTA DR STE 2180
-----------------------------------------------------
City | CITRUS HEIGHTS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95610-7057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-548-6018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | LAQUIA MONIQUE JENKINS
-----------------------------------------------------
Credential | CMT
-----------------------------------------------------
Telephone | 916-879-9190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133NN1002X
-----------------------------------------------------
Taxonomy Name | Nutrition Education Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 173C00000X
-----------------------------------------------------
Taxonomy Name | Reflexologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------