Provider Demographics
NPI:1790054674
Name:RICH, MARK ELLIS (NCTMB)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ELLIS
Last Name:RICH
Suffix:
Gender:M
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 S HILLSDALE RD
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9367
Mailing Address - Country:US
Mailing Address - Phone:517-439-4263
Mailing Address - Fax:517-439-4263
Practice Address - Street 1:1342 S HILLSDALE RD
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9367
Practice Address - Country:US
Practice Address - Phone:517-439-4263
Practice Address - Fax:517-439-4263
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI610877-11225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI610877-11OtherNATIONAL CERTIFICATION BOARD THERAPEUTIC MASSAGE & BODYWORK