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General NPI Number Information
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NPI Number | 1972913929
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Entity Type | Organization
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Legal Business Name | SERENITY THERAPEUTIC MASSAGE
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Dates
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Enumeration Date | 04/29/2014
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Last Update Date | 04/29/2014
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Provider Practice Location Address
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Address Line | 11953 S APOPKA VINELAND RD
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City | ORLANDO
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State | FL
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Zip | 32836-7025
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Country | US
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Telephone | 863-337-4463
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Fax |
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Provider Business Mailing Address
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Address Line | 929 GILMORE AVE APT 34
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City | LAKELAND
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State | FL
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Zip | 33801-1887
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Country | US
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Telephone | 863-337-4463
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Fax |
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Authorized Official
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Title or Position | OWNER / THERAPIST
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Name | MR. CARL HENDERSON SR.
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Credential | LMT
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Telephone | 863-337-4463
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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 | MA75231
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License Number State | FL
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