Provider Demographics
NPI:1780093617
Name:MIRACLE MASSAGE AND THERAPY CENTER CORP
Entity type:Organization
Organization Name:MIRACLE MASSAGE AND THERAPY CENTER CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BORREGO
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:502-762-5645
Mailing Address - Street 1:3715 BARDSTOWN RD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2244
Mailing Address - Country:US
Mailing Address - Phone:502-762-5645
Mailing Address - Fax:502-454-7784
Practice Address - Street 1:3715 BARDSTOWN RD
Practice Address - Street 2:SUITE 217
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2244
Practice Address - Country:US
Practice Address - Phone:502-762-5645
Practice Address - Fax:502-454-7784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center