1053564666 NPI number — BALLAURA INCORPORATED

Table of content: (NPI 1053564666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053564666 NPI number — BALLAURA INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALLAURA INCORPORATED
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:
BALLAURA MASSAGE
Provider Other Organization Name Type Code:
5
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:
1053564666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98509-8022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-539-7726
Provider Business Mailing Address Fax Number:
360-539-7729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2413 PACIFIC AVE SE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98501-2087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-539-7726
Provider Business Practice Location Address Fax Number:
360-539-7729
Provider Enumeration Date:
10/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BALL
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-539-7726

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MA00022961 , 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)





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