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General NPI Number Information
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NPI Number | 1447679527
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Entity Type | Organization
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Legal Business Name | MOBILE MASSAGE, LLC
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Dates
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Enumeration Date | 04/16/2014
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Last Update Date | 04/16/2014
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Provider Practice Location Address
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Address Line | 307 MAPLE AVE W
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City | VIENNA
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State | VA
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Zip | 22180-4307
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Country | US
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Telephone | 240-778-8187
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Fax |
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Provider Business Mailing Address
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Address Line | 307 MAPLE AVE W
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City | VIENNA
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State | VA
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Zip | 22180-4307
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Country | US
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Telephone |
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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 | WILLIAM QUELL PATRICK JR.
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Credential | LMT
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Telephone | 240-778-8187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 0019011159
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License Number State | VA
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