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General NPI Number Information
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NPI Number | 1740433606
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Entity Type | Organization
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Legal Business Name | JOHN R. ELLIS MASSAGE, INC.
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Dates
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Enumeration Date | 10/23/2008
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Last Update Date | 10/23/2008
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Provider Practice Location Address
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Address Line | 12621 NEW BRITTANY BLVD SUITE 17W
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City | FORT MYERS
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State | FL
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Zip | 33907-3631
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Country | US
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Telephone | 239-872-4641
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 BRANTLEY RD #801
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City | FORT MYERS
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State | FL
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Zip | 33907-3994
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Country | US
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Telephone | 239-872-4641
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | JOHN R. ELLIS
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Credential | LMT
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Telephone | 239-872-4641
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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 | MA40808
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License Number State | FL
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