Provider Demographics
NPI:1336533652
Name:SOUTHERN THERAPEUTIC MASSAGE STUDIO LLC
Entity Type:Organization
Organization Name:SOUTHERN THERAPEUTIC MASSAGE STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:NMT
Authorized Official - Phone:229-328-0937
Mailing Address - Street 1:88 W. BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730
Mailing Address - Country:US
Mailing Address - Phone:229-328-0937
Mailing Address - Fax:
Practice Address - Street 1:88 W. BROAD ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730
Practice Address - Country:US
Practice Address - Phone:229-328-0937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty