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General NPI Number Information
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NPI Number | 1780093617
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Entity Type | Organization
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Legal Business Name | MIRACLE MASSAGE AND THERAPY CENTER CORP
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Dates
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Enumeration Date | 08/05/2014
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Last Update Date | 08/05/2014
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Provider Practice Location Address
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Address Line | 3715 BARDSTOWN RD SUITE 217
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City | LOUISVILLE
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State | KY
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Zip | 40218-2244
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Country | US
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Telephone | 502-762-5645
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Fax | 502-454-7784
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Provider Business Mailing Address
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Address Line | 3715 BARDSTOWN RD SUITE 217
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City | LOUISVILLE
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State | KY
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Zip | 40218-2244
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Country | US
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Telephone | 502-762-5645
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Fax | 502-454-7784
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Authorized Official
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Title or Position | PRESIDENT
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Name | ARIEL BORREGO
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Credential | PRESIDENT
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Telephone | 502-762-5645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | KY
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