Provider Demographics
NPI:1770395097
Name:MARK'S EFFECTUAL MASSAGE EXPERIENCE
Entity type:Organization
Organization Name:MARK'S EFFECTUAL MASSAGE EXPERIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CPT
Authorized Official - Phone:337-718-6517
Mailing Address - Street 1:12395 LAKE CHARLES HWY
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-5804
Mailing Address - Country:US
Mailing Address - Phone:337-718-6517
Mailing Address - Fax:
Practice Address - Street 1:12395 LAKE CHARLES HWY
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-5804
Practice Address - Country:US
Practice Address - Phone:337-718-6517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty