Provider Demographics
NPI:1679949820
Name:INNER COURT HOLISTIC DAY SPA
Entity Type:Organization
Organization Name:INNER COURT HOLISTIC DAY SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:904-444-7286
Mailing Address - Street 1:PO BOX 28686
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-8686
Mailing Address - Country:US
Mailing Address - Phone:904-885-7344
Mailing Address - Fax:
Practice Address - Street 1:9951 ATLANTIC BLVD
Practice Address - Street 2:SUITE 314
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6584
Practice Address - Country:US
Practice Address - Phone:904-444-7286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA69978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002087688OtherDUN