=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740037910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THEE BODY BAR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2024
-----------------------------------------------------
Last Update Date | 05/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2084 DUNBARTON DR STE H
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-5016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-798-6814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 262 IRIS AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39206-3905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-798-6814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MT
-----------------------------------------------------
Name | MS. CONESHA MICHAEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 769-798-6814
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------