MEDICARE: SOUTHERN SELECT MASSAGE THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1356273379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN SELECT MASSAGE THERAPY LLC

Provider Business Mailing Address
First Line	:	12518 WYNDY AVE
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-4759
Country	:	US
Telephone Number	:	225-448-4499
Fax Number	:

Provider Business Practice Location Address
First Line	:	1433 OLD HAMOND HWY , 302B
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816
Country	:	US
Telephone Number	:	225-272-1401
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TREY JOSEPH IVERSTINE
Credential	:	LMT
Telephone Number	:	225-448-4499

Provider Enumeration Date	:	06/02/2026
Last Update Date	:	06/02/2026

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