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General NPI Number Information
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NPI Number | 1548686876
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Entity Type | Individual
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Provider Name | MRS. LISA MARIE LONGORIA I
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Gender | Female
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Dates
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Enumeration Date | 03/11/2014
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Last Update Date | 03/11/2014
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Provider Practice Location Address
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Address Line | 17615 BAILEY RD
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City | BAILEY
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State | MI
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Zip | 49303-9729
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Country | US
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Telephone | 616-914-7362
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Fax | 231-282-7057
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Provider Business Mailing Address
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Address Line | 17165 BAILEY RD
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City | BAILEY
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State | MI
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Zip | 49303-9729
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Country | US
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Telephone | 616-914-7362
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Fax | 231-282-7057
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 7501002188
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License Number State | MI
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