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General NPI Number Information
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NPI Number | 1730745282
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Entity Type | Organization
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Legal Business Name | PANACEA WELLNESS STUDIO LLC
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Dates
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Enumeration Date | 05/09/2019
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Last Update Date | 05/09/2019
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Provider Practice Location Address
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Address Line | 17 N COUNTRY RD STE B
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2271
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Country | US
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Telephone | 631-509-4270
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Fax | 631-509-4271
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Provider Business Mailing Address
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Address Line | 17 N COUNTRY RD STE B
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2271
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Country | US
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Telephone | 631-509-4270
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Fax | 631-509-4271
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Authorized Official
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Title or Position | OWNER
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Name | MISS VANESSA JOHNATHAN
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Credential | LMT
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Telephone | 516-427-0394
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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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