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General NPI Number Information
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NPI Number | 1639629355
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Entity Type | Organization
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Legal Business Name | EBONEE'S MASSAGE MECCA
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Dates
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Enumeration Date | 10/05/2016
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Last Update Date | 10/05/2016
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Provider Practice Location Address
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Address Line | 1150 W ROBINHOOD DR SUITE 5A
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City | STOCKTON
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State | CA
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Zip | 95207-5624
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Country | US
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Telephone | 209-910-0226
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Fax |
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Provider Business Mailing Address
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Address Line | 1150 W ROBINHOOD DR SUITE 5A
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City | STOCKTON
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State | CA
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Zip | 95207-5624
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Country | US
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Telephone | 209-910-0226
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | EBONEE TAYLOR
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Credential | LMT
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Telephone | 209-910-0226
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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 | 482
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License Number State | CA
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