Provider Demographics
NPI:1699213058
Name:TABLE FOR ONE MASSAGE THERAPY
Entity Type:Organization
Organization Name:TABLE FOR ONE MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ST JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:RN LMT
Authorized Official - Phone:906-367-2060
Mailing Address - Street 1:412 MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49920
Mailing Address - Country:US
Mailing Address - Phone:906-367-2060
Mailing Address - Fax:
Practice Address - Street 1:412 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL FALLS
Practice Address - State:MI
Practice Address - Zip Code:49920-1416
Practice Address - Country:US
Practice Address - Phone:906-367-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC20010018251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care