Provider Demographics
NPI:1154099570
Name:EAST END SPORTS MASSAGE
Entity Type:Organization
Organization Name:EAST END SPORTS MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:718-683-1905
Mailing Address - Street 1:2595 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:ORIENT
Mailing Address - State:NY
Mailing Address - Zip Code:11957-1469
Mailing Address - Country:US
Mailing Address - Phone:718-683-1905
Mailing Address - Fax:
Practice Address - Street 1:222 MANOR PL STE 7
Practice Address - Street 2:
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-1261
Practice Address - Country:US
Practice Address - Phone:631-268-4769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty