Provider Demographics
NPI: | 1649743352 |
---|---|
Name: | WYATT DEMARCO MASSAGE THERAPY & WELLNESS CENTER |
Entity Type: | Organization |
Organization Name: | WYATT DEMARCO MASSAGE THERAPY & WELLNESS CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JESSICA |
Authorized Official - Middle Name: | R |
Authorized Official - Last Name: | WYATT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LMT |
Authorized Official - Phone: | 440-225-4555 |
Mailing Address - Street 1: | 690 AVON BELDEN RD |
Mailing Address - Street 2: | 2C |
Mailing Address - City: | AVON LAKE |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 44012 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 440-225-4555 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 690 AVON BELDEN RD |
Practice Address - Street 2: | 2C |
Practice Address - City: | AVON LAKE |
Practice Address - State: | OH |
Practice Address - Zip Code: | 44012 |
Practice Address - Country: | US |
Practice Address - Phone: | 440-225-4555 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2019-01-04 |
Last Update Date: | 2019-01-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225700000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | Group - Single Specialty |