Provider Demographics
NPI:1598244253
Name:MEDICAL MASSAGE OF COWETA, LLC
Entity Type:Organization
Organization Name:MEDICAL MASSAGE OF COWETA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, MMP
Authorized Official - Phone:678-590-8040
Mailing Address - Street 1:3025B SHARPSBURG MCCULLUM RD STE 108
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6107
Mailing Address - Country:US
Mailing Address - Phone:678-590-8040
Mailing Address - Fax:347-823-8404
Practice Address - Street 1:3025B SHARPSBURG MCCULLUM RD STE 108
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6107
Practice Address - Country:US
Practice Address - Phone:678-590-8040
Practice Address - Fax:347-823-8404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT002072225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1619176278Medicaid