Provider Demographics
NPI:1780648386
Name:MEDICAL MASAGE CENTER, INC.
Entity Type:Organization
Organization Name:MEDICAL MASAGE CENTER, INC.
Other - Org Name:COLORADO WELLNESS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:303-979-0342
Mailing Address - Street 1:8370 W COAL MINE AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80123-4401
Mailing Address - Country:US
Mailing Address - Phone:303-979-0342
Mailing Address - Fax:303-979-3872
Practice Address - Street 1:8370 W COAL MINE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80123-4401
Practice Address - Country:US
Practice Address - Phone:303-979-0342
Practice Address - Fax:303-979-3872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherTAX IDENTIFICATION