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General NPI Number Information
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NPI Number | 1295163319
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Entity Type | Organization
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Legal Business Name | THE MIRACLE OF MASSAGE, INC.
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Dates
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Enumeration Date | 10/29/2013
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Last Update Date | 10/29/2013
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Provider Practice Location Address
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Address Line | 5300 MEMORIAL DR SUITE 138
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3148
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Country | US
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Telephone | 678-883-2873
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Fax | 800-975-1805
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Provider Business Mailing Address
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Address Line | 5300 MEMORIAL DR SUITE 138
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3148
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Country | US
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Telephone | 678-883-2873
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Fax | 800-975-1805
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Authorized Official
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Title or Position | CEO/ LICENSED MASSAGE THERAPIST
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Name | MR. BRIAN WALTERS SR.
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Credential | LMT
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Telephone | 678-883-2873
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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 | MT007445
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License Number State | GA
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