Provider Demographics
NPI:1578298154
Name:TAVARES, MEESHA (LMT)
Entity Type:Individual
Prefix:
First Name:MEESHA
Middle Name:
Last Name:TAVARES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11641 ELLIOTT RD
Mailing Address - Street 2:
Mailing Address - City:CUSTER
Mailing Address - State:SD
Mailing Address - Zip Code:57730-8238
Mailing Address - Country:US
Mailing Address - Phone:208-971-5356
Mailing Address - Fax:
Practice Address - Street 1:405 E OMAHA ST STE D
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2974
Practice Address - Country:US
Practice Address - Phone:605-348-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT11919225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist