1730063819 NPI number — SUCHAYA THAI MASSAGE LLC

Table of content: DR. KELLY CORINNE BLAKE O.D. (NPI 1801042171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730063819 NPI number — SUCHAYA THAI MASSAGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUCHAYA THAI MASSAGE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730063819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
541 SE WOODS EDGE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34997-6374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-939-4565
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2480 SE FEDERAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-4531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-324-8196
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/02/2025

Additional Information

Authorized Official

Authorized Official Last Name:
CONCESSI
Authorized Official First Name:
SUCHAYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-939-4565

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1306720545 . This is a "MASSAGE THERAPY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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