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General NPI Number Information
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NPI Number | 1326315433
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Entity Type | Organization
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Legal Business Name | MASSAGE TEA LC
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Dates
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Enumeration Date | 11/18/2011
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Last Update Date | 11/18/2011
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Provider Practice Location Address
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Address Line | 27003 PLYMOUTH RD
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City | REDFORD
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State | MI
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Zip | 48239-2343
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Country | US
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Telephone | 313-744-7055
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4388
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City | DETROIT
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State | MI
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Zip | 48204-0388
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Country | US
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Telephone | 313-516-5536
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANDRE LATELY
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Credential |
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Telephone | 313-516-5536
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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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