Provider Demographics
NPI:1396120598
Name:MASSAGE ON DA GO LLC
Entity type:Organization
Organization Name:MASSAGE ON DA GO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWANDA
Authorized Official - Middle Name:EUNICE
Authorized Official - Last Name:CHANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-591-6485
Mailing Address - Street 1:199 ROSEMARY DR APT 4
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-3977
Mailing Address - Country:US
Mailing Address - Phone:901-591-6485
Mailing Address - Fax:
Practice Address - Street 1:199 ROSEMARY DR APT 4
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-3977
Practice Address - Country:US
Practice Address - Phone:901-591-6485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2038225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty