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General NPI Number Information
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NPI Number | 1770395097
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Entity Type | Organization
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Legal Business Name | MARK'S EFFECTUAL MASSAGE EXPERIENCE
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Dates
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Enumeration Date | 01/23/2025
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Last Update Date | 01/23/2025
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Provider Practice Location Address
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Address Line | 12395 LAKE CHARLES HWY
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City | LEESVILLE
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State | LA
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Zip | 71446-5804
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Country | US
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Telephone | 337-718-6517
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Fax |
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Provider Business Mailing Address
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Address Line | 12395 LAKE CHARLES HWY
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City | LEESVILLE
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State | LA
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Zip | 71446-5804
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Country | US
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Telephone | 337-718-6517
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Fax |
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Authorized Official
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Title or Position | CEO/COO
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Name | MR. MARK GREGORY
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Credential | LMT, CPT
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Telephone | 337-718-6517
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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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