Provider Demographics
NPI:1528814803
Name:LILY OF THE VALLEY MASSAGE LLC
Entity type:Organization
Organization Name:LILY OF THE VALLEY MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALLON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-302-1357
Mailing Address - Street 1:1882 SW MACARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3174 NW FEDERAL HWY STE 3490
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4450
Practice Address - Country:US
Practice Address - Phone:623-302-1357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty