Provider Demographics
NPI:1568831485
Name:INDIGO EARTH SPA
Entity Type:Organization
Organization Name:INDIGO EARTH SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL MASSAGE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, FS
Authorized Official - Phone:850-303-3669
Mailing Address - Street 1:443 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2721
Mailing Address - Country:US
Mailing Address - Phone:850-303-3669
Mailing Address - Fax:850-252-6030
Practice Address - Street 1:443 GRACE AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2721
Practice Address - Country:US
Practice Address - Phone:850-303-3669
Practice Address - Fax:850-252-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA63341261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation