Provider Demographics
NPI:1932475167
Name:MEDSPORTS PROMASSAGE
Entity Type:Organization
Organization Name:MEDSPORTS PROMASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:COLEMAN
Authorized Official - Last Name:HAMID
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:904-505-0575
Mailing Address - Street 1:PO BOX 8565
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32006-0014
Mailing Address - Country:US
Mailing Address - Phone:904-505-0575
Mailing Address - Fax:
Practice Address - Street 1:3491 PALL MALL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5449
Practice Address - Country:US
Practice Address - Phone:904-505-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA36322305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization