1770620064 NPI number — CLARK THERAPEUTIC MASSAGE

Table of content: (NPI 1770620064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770620064 NPI number — CLARK THERAPEUTIC MASSAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARK THERAPEUTIC MASSAGE
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:
1770620064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98338-0988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-847-2687
Provider Business Mailing Address Fax Number:
253-846-3012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10107 213TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98338-8059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-847-2687
Provider Business Practice Location Address Fax Number:
253-846-3012
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
PATRICIA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
253-847-2687

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00004428 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 66473 . This is a "L&I NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7694CL . This is a "REGENCE PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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