Provider Demographics
NPI:1164707832
Name:MIRACLE MASSAGE AND REHAB CORP
Entity Type:Organization
Organization Name:MIRACLE MASSAGE AND REHAB CORP
Other - Org Name:MIRACLE MASSAGE AND REHAB CORP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANYELEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MESA
Authorized Official - Suffix:
Authorized Official - Credentials:MA 61548
Authorized Official - Phone:305-887-8701
Mailing Address - Street 1:624 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-4552
Mailing Address - Country:US
Mailing Address - Phone:305-887-8701
Mailing Address - Fax:305-887-8705
Practice Address - Street 1:624 E 9TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-4552
Practice Address - Country:US
Practice Address - Phone:305-887-8701
Practice Address - Fax:305-887-8705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 61548173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173C00000XOther Service ProvidersReflexologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherMASSAGE ESTABLISHMENT