Provider Demographics
NPI:1396222485
Name:MYSTIC PARADISE LLC
Entity Type:Organization
Organization Name:MYSTIC PARADISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:SHILTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-638-2113
Mailing Address - Street 1:RR 3 BOX 308A
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-9518
Mailing Address - Country:US
Mailing Address - Phone:304-638-2113
Mailing Address - Fax:
Practice Address - Street 1:1765 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-2552
Practice Address - Country:US
Practice Address - Phone:304-638-2113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty