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General NPI Number Information
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NPI Number | 1790035749
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Entity Type | Organization
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Legal Business Name | ISLAND THERAPEUTIC MASSAGE
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Dates
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Enumeration Date | 09/18/2012
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Last Update Date | 09/19/2012
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Provider Practice Location Address
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Address Line | 6043 HUDSON RD SUITE 125
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City | WOODBURY
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State | MN
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Zip | 55125-1018
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Country | US
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Telephone | 612-735-0610
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Fax |
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Provider Business Mailing Address
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Address Line | 6043 HUDSON RD SUITE 125
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City | WOODBURY
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State | MN
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Zip | 55125-1018
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Country | US
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Telephone | 612-735-0610
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | VICTORIA STOVALL
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Credential |
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Telephone | 612-735-0610
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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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