Provider Demographics
NPI:1881225142
Name:MIGHTY MASSAGE INC
Entity type:Organization
Organization Name:MIGHTY MASSAGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KUCERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-498-1986
Mailing Address - Street 1:2514 POLK ST NE # 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3730
Mailing Address - Country:US
Mailing Address - Phone:763-498-1986
Mailing Address - Fax:612-378-1051
Practice Address - Street 1:2514 POLK ST NE # 2
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-3730
Practice Address - Country:US
Practice Address - Phone:763-498-1986
Practice Address - Fax:612-378-1051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6608778OtherSTATE ID NUMBER