Provider Demographics
NPI:1295163319
Name:THE MIRACLE OF MASSAGE, INC.
Entity type:Organization
Organization Name:THE MIRACLE OF MASSAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:SR
Authorized Official - Credentials:LMT
Authorized Official - Phone:678-883-2873
Mailing Address - Street 1:5300 MEMORIAL DR
Mailing Address - Street 2:SUITE 138
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3148
Mailing Address - Country:US
Mailing Address - Phone:678-883-2873
Mailing Address - Fax:800-975-1805
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:SUITE 138
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3148
Practice Address - Country:US
Practice Address - Phone:678-883-2873
Practice Address - Fax:800-975-1805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007445225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty