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General NPI Number Information
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NPI Number | 1699213058
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Entity Type | Organization
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Legal Business Name | TABLE FOR ONE MASSAGE THERAPY
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Dates
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Enumeration Date | 02/06/2017
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Last Update Date | 02/06/2017
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Provider Practice Location Address
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Address Line | 412 MICHIGAN AVE
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City | CRYSTAL FALLS
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State | MI
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Zip | 49920-1416
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Country | US
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Telephone | 906-367-2060
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Fax |
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Provider Business Mailing Address
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Address Line | 412 MICHIGAN AVENUE
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City | CRYSTAL FALLS
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State | MI
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Zip | 49920
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Country | US
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Telephone | 906-367-2060
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Fax |
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST
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Name | MISS TINA MARIE ST JOHN
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Credential | RN LMT
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Telephone | 906-367-2060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | C20010018
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License Number State | MI
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