Provider Demographics
NPI:1023358199
Name:DEEP KNEAD MEDSPA
Entity Type:Organization
Organization Name:DEEP KNEAD MEDSPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:REGINA
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:352-514-9887
Mailing Address - Street 1:4109 NW 44TH CT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-4507
Mailing Address - Country:US
Mailing Address - Phone:352-514-9887
Mailing Address - Fax:352-372-3159
Practice Address - Street 1:117 NW MONROE AVE
Practice Address - Street 2:
Practice Address - City:MAYO
Practice Address - State:FL
Practice Address - Zip Code:32066
Practice Address - Country:US
Practice Address - Phone:352-514-9887
Practice Address - Fax:352-372-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-26
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA24270225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8022OtherBCBSFL