Provider Demographics
NPI:1639976988
Name:BACCHUS, TAMEEKA N
Entity type:Individual
Prefix:
First Name:TAMEEKA
Middle Name:N
Last Name:BACCHUS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PHENIX SALON SUITES 25300 ROCKAWAY BLVD
Mailing Address - Street 2:SUITE125
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422
Mailing Address - Country:US
Mailing Address - Phone:646-379-0496
Mailing Address - Fax:
Practice Address - Street 1:25300 ROCKAWAY BLVD
Practice Address - Street 2:SUITE125
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422
Practice Address - Country:US
Practice Address - Phone:646-379-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027065-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty