Provider Demographics
NPI:1003078387
Name:MYSTIC MASSAGE
Entity Type:Organization
Organization Name:MYSTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GOODE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:404-914-1822
Mailing Address - Street 1:2408 SUMMERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-3054
Mailing Address - Country:US
Mailing Address - Phone:404-914-1822
Mailing Address - Fax:
Practice Address - Street 1:8725 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-7533
Practice Address - Country:US
Practice Address - Phone:404-914-1822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT000319174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty