Provider Demographics
NPI:1558894121
Name:CONCIERGE MASSAGE THERAPY, LLC
Entity Type:Organization
Organization Name:CONCIERGE MASSAGE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:PASSMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMT, MMP
Authorized Official - Phone:985-662-0991
Mailing Address - Street 1:1402 S MAGNOLIA ST
Mailing Address - Street 2:D
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5020
Mailing Address - Country:US
Mailing Address - Phone:985-662-0991
Mailing Address - Fax:985-662-0976
Practice Address - Street 1:1402 S MAGNOLIA ST
Practice Address - Street 2:D
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5020
Practice Address - Country:US
Practice Address - Phone:985-662-0991
Practice Address - Fax:985-662-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAE3591225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty