Provider Demographics
NPI:1104253285
Name:MASSAGE REVOLUTION
Entity type:Organization
Organization Name:MASSAGE REVOLUTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-918-1853
Mailing Address - Street 1:210 E CAPITOL ST
Mailing Address - Street 2:SUITE M-142
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39201-2306
Mailing Address - Country:US
Mailing Address - Phone:601-918-1853
Mailing Address - Fax:
Practice Address - Street 1:210 E CAPITOL ST
Practice Address - Street 2:SUITE M-142
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-2306
Practice Address - Country:US
Practice Address - Phone:601-918-1853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2027225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty