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General NPI Number Information
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NPI Number | 1982399564
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Entity Type | Organization
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Legal Business Name | THE MAGNOLIA DAY SPA LLC
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Dates
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Enumeration Date | 04/10/2023
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Last Update Date | 04/10/2023
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Provider Practice Location Address
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Address Line | 4280 HARLOW BLVD
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City | GREENVILLE
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State | MS
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Zip | 38701-6604
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Country | US
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Telephone | 662-390-4920
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Fax |
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Provider Business Mailing Address
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Address Line | 4280 HARLOW BLVD
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City | GREENVILLE
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State | MS
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Zip | 38701-6604
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Country | US
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Telephone | 662-390-4920
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Fax |
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST / OWNER
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Name | MRS. CANDACE MIYORI MINOR
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Credential | LMT # 2004
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Telephone | 662-390-4920
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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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