1710698519 NPI number — FRUITFUL VIBRATIONS LLC

Table of content: (NPI 1710698519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710698519 NPI number — FRUITFUL VIBRATIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRUITFUL VIBRATIONS 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:
1710698519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 BLAINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14208-1018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-939-7222
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2871 GENESEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14225-3141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-939-7222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2022

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
IESHA
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
716-939-7222

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 374J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 032732 . This is a "NY OFFICE OF PROFESSIONS MASSAGE THERAPY LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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