Provider Demographics
NPI:1780918961
Name:MEDICAL MASSAGE OF DELAWARE
Entity type:Organization
Organization Name:MEDICAL MASSAGE OF DELAWARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMT
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-757-1951
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:DE
Mailing Address - Zip Code:19708-0240
Mailing Address - Country:US
Mailing Address - Phone:888-757-1951
Mailing Address - Fax:
Practice Address - Street 1:105 MEGAN DR
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-2085
Practice Address - Country:US
Practice Address - Phone:888-757-1951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT0001873174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty