Provider Demographics
NPI:1104356591
Name:LAKEWOOD RANCH MEDICAL MASSAGE, LLC
Entity Type:Organization
Organization Name:LAKEWOOD RANCH MEDICAL MASSAGE, LLC
Other - Org Name:MAD SCIENCE MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:941-321-5311
Mailing Address - Street 1:11161 E STATE ROAD 70 STE 110-360
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9407
Mailing Address - Country:US
Mailing Address - Phone:941-321-5311
Mailing Address - Fax:
Practice Address - Street 1:9070 58TH DR E STE 102
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-6110
Practice Address - Country:US
Practice Address - Phone:941-321-5311
Practice Address - Fax:941-321-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA40424225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty