1073975488 NPI number — LAKEVIEW MASSAGE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073975488 NPI number — LAKEVIEW MASSAGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEVIEW 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:
1073975488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13465 PILOT KNOB RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLE VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55124-8693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-423-3420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13465 PILOT KNOB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55124-8693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-423-3420
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
TOUSIGNANT
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OWNER/MASSAGE THERAPIST
Authorized Official Telephone Number:
952-423-3420

Provider Taxonomy Codes

  • Taxonomy code: 320700000X , with the licence number:  MT-2016-21 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MT-2016-21 . This is a "CITY LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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