Provider Demographics
NPI:1598350993
Name:TAKERA'S THERAPEUTIC MASSAGE PLLC
Entity Type:Organization
Organization Name:TAKERA'S THERAPEUTIC MASSAGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAKERA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWERY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:131-367-6888
Mailing Address - Street 1:26150 5 MILE RD STE 1D
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-3244
Mailing Address - Country:US
Mailing Address - Phone:313-676-8889
Mailing Address - Fax:
Practice Address - Street 1:26150 5 MILE RD STE 1D
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-3244
Practice Address - Country:US
Practice Address - Phone:313-676-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669078903Medicaid