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General NPI Number Information
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NPI Number | 1689251712
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Entity Type | Organization
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Legal Business Name | MOUNTAINSIDE DIVERSIFIED
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Dates
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Enumeration Date | 03/25/2021
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Last Update Date | 03/25/2021
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Provider Practice Location Address
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Address Line | 1324 FOREST AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10302-2044
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Country | US
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Telephone | 877-480-8038
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 20521
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City | STATEN ISLAND
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State | NY
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Zip | 10302-0521
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Country | US
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Telephone | 877-480-8038
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Fax |
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Authorized Official
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Title or Position | PARTNER/MANAGER
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Name | HEATHER MILLER
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Credential | LMT, BCTMB
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Telephone | 877-480-8038
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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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