Provider Demographics
NPI:1821345356
Name:SOUTHEASTERN NEUROMUSCULAR MASSAGE THERAPY, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN NEUROMUSCULAR MASSAGE THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-383-4934
Mailing Address - Street 1:112 N. MADISON AVE.
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533
Mailing Address - Country:US
Mailing Address - Phone:912-383-4934
Mailing Address - Fax:912-383-4934
Practice Address - Street 1:112 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-4604
Practice Address - Country:US
Practice Address - Phone:912-383-4934
Practice Address - Fax:912-383-4934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207R00000X
GAMT003853225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty