Provider Demographics
NPI:1295483147
Name:MELLOW MASSAGE LTD.
Entity type:Organization
Organization Name:MELLOW MASSAGE LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERRAE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMONS MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-297-5085
Mailing Address - Street 1:132 E WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-2005
Mailing Address - Country:US
Mailing Address - Phone:856-297-5085
Mailing Address - Fax:
Practice Address - Street 1:4023 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1544
Practice Address - Country:US
Practice Address - Phone:856-297-5085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center