Provider Demographics
NPI:1801529151
Name:MIRACULOUS MASSAGE THERAPIST LLC
Entity type:Organization
Organization Name:MIRACULOUS MASSAGE THERAPIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CHAPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-290-7689
Mailing Address - Street 1:1924 ASHBURN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-0826
Mailing Address - Country:US
Mailing Address - Phone:702-290-7689
Mailing Address - Fax:
Practice Address - Street 1:5803 W CRAIG RD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2537
Practice Address - Country:US
Practice Address - Phone:702-290-7689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty