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General NPI Number Information
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NPI Number | 1740317635
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Entity Type | Organization
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Legal Business Name | SPACE COAST MASSAGE THERAPY INC.
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1070 S WICKHAM RD
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City | WEST MELBOURNE
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State | FL
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Zip | 32904-1653
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Country | US
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Telephone | 321-729-9000
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Fax | 321-722-3997
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Provider Business Mailing Address
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Address Line | 1070 S WICKHAM RD
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City | WEST MELBOURNE
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State | FL
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Zip | 32904-1653
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Country | US
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Telephone | 321-729-9000
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Fax | 321-722-3997
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Authorized Official
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Title or Position | PROPRIETOR
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Name | MRS. JODY STORK I
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Credential | LMT
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Telephone | 321-729-9000
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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 | MM3853
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License Number State | FL
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