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General NPI Number Information
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NPI Number | 1760870224
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Entity Type | Organization
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Legal Business Name | AMANDAS MINI DAY SPA
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Dates
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Enumeration Date | 01/06/2015
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Last Update Date | 01/06/2015
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Provider Practice Location Address
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Address Line | 510 E CHAIN OF ROCKS RD
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City | GRANITE CITY
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State | IL
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Zip | 62040-2803
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Country | US
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Telephone | 314-467-0766
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Fax |
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Provider Business Mailing Address
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Address Line | 510 E CHAIN OF ROCKS RD
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City | GRANITE CITY
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State | IL
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Zip | 62040-2803
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Country | US
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Telephone | 314-467-0766
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. AMANDA RANSOM
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Credential | LMT
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Telephone | 314-467-0766
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 2001010642
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License Number State | MO
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