Provider Demographics
NPI:1760898506
Name:FOOTPRINTS ON THE MOON MASSAGE AND BODYWORK, LLC
Entity Type:Organization
Organization Name:FOOTPRINTS ON THE MOON MASSAGE AND BODYWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:FAGNANT
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:407-436-2122
Mailing Address - Street 1:1312 ILLINOIS AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4506
Mailing Address - Country:US
Mailing Address - Phone:407-436-2122
Mailing Address - Fax:
Practice Address - Street 1:1312 ILLINOIS AVE
Practice Address - Street 2:SUITE E
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4506
Practice Address - Country:US
Practice Address - Phone:407-436-2122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM32405225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty