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General NPI Number Information
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NPI Number | 1952623704
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Entity Type | Organization
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Legal Business Name | MODERN MEDICAL MASSAGE, LLC
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Dates
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Enumeration Date | 02/22/2010
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Last Update Date | 02/22/2010
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Provider Practice Location Address
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Address Line | 664 SCRANTON RD
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City | BRUNSWICK
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State | GA
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Zip | 31520-1945
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Country | US
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Telephone | 912-577-3991
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Fax |
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Provider Business Mailing Address
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Address Line | 211 WELLINGTON PL
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City | BRUNSWICK
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State | GA
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Zip | 31523-7067
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Country | US
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Telephone | 912-577-3991
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | AIMEE S JONGEJAN
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Credential |
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Telephone | 912-577-3991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MT002240
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License Number State | GA
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