Provider Demographics
NPI:1194982140
Name:EDEN MASSAGE & SPA, INC
Entity type:Organization
Organization Name:EDEN MASSAGE & SPA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:OKON
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:954-564-9536
Mailing Address - Street 1:2655 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1608
Mailing Address - Country:US
Mailing Address - Phone:954-564-9536
Mailing Address - Fax:954-565-2910
Practice Address - Street 1:2655 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE #2
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1608
Practice Address - Country:US
Practice Address - Phone:954-564-9536
Practice Address - Fax:954-565-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLIC #19555225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686157196OtherMED WAIVER