Provider Demographics
NPI:1952664898
Name:MYSTIC MYRTLES STUFF LLC
Entity Type:Organization
Organization Name:MYSTIC MYRTLES STUFF LLC
Other - Org Name:MYSTIC MYRTLES STUFF LLC MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-753-3148
Mailing Address - Street 1:1711 N STOCKTON HILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4673
Mailing Address - Country:US
Mailing Address - Phone:928-753-3148
Mailing Address - Fax:928-753-3148
Practice Address - Street 1:1711 N STOCKTON HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4673
Practice Address - Country:US
Practice Address - Phone:928-753-3148
Practice Address - Fax:928-753-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT04442P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty