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General NPI Number Information
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NPI Number | 1376728154
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Entity Type | Organization
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Legal Business Name | MASSAGE THERAPEUTICS, INC CENTER FOR WELLNESS
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Dates
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Enumeration Date | 12/30/2007
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Last Update Date | 09/24/2013
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Provider Practice Location Address
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Address Line | 500 LANIER AVE W STE 411
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-7638
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Country | US
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Telephone | 404-765-0798
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Fax |
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Provider Business Mailing Address
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Address Line | 8299 DEWAYNE LN
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City | JONESBORO
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State | GA
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Zip | 30236-3710
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Country | US
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Telephone | 404-765-0798
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Fax |
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Authorized Official
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Title or Position | CEO/NEUROMUSCULAR THERAPIST
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Name | MRS. URSULA JACINTA EDWARDS ELLERBY
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Credential | LMT, NMT
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Telephone | 404-765-0798
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | MT003516
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License Number State | GA
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