Provider Demographics
NPI:1164979084
Name:THE WELLNESS SPA, LLC
Entity Type:Organization
Organization Name:THE WELLNESS SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT 1384
Authorized Official - Phone:601-479-5392
Mailing Address - Street 1:5419 HIGHWAY 25 STE R
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-6343
Mailing Address - Country:US
Mailing Address - Phone:601-479-5392
Mailing Address - Fax:
Practice Address - Street 1:5419 HIGHWAY 25 STE R
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6343
Practice Address - Country:US
Practice Address - Phone:601-479-5392
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty