Provider Demographics
NPI:1649897786
Name:MDJ MASSAGE LLC
Entity type:Organization
Organization Name:MDJ MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARYELLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NORIEGA
Authorized Official - Suffix:
Authorized Official - Credentials:LMT NCTMB
Authorized Official - Phone:229-262-8008
Mailing Address - Street 1:4017 GREY OAK DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5865
Mailing Address - Country:US
Mailing Address - Phone:229-262-8008
Mailing Address - Fax:
Practice Address - Street 1:4017 GREY OAK DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-5865
Practice Address - Country:US
Practice Address - Phone:229-262-8008
Practice Address - Fax:229-232-4743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-05
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty