Provider Demographics
NPI:1619425261
Name:BLESSEDTOUCH THERAPUTIC MASSAGE & NUTRITION
Entity Type:Organization
Organization Name:BLESSEDTOUCH THERAPUTIC MASSAGE & NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:RICHARDEAN
Authorized Official - Middle Name:CLOVENA
Authorized Official - Last Name:GIBSON WINGATE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:843-245-4708
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29503-0376
Mailing Address - Country:US
Mailing Address - Phone:843-245-4708
Mailing Address - Fax:843-407-6607
Practice Address - Street 1:605 S DARGAN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2544
Practice Address - Country:US
Practice Address - Phone:843-245-4708
Practice Address - Fax:843-407-6607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS 7994305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service