1265606198 NPI number — CLASSIC MASSAGE CLINIC, PLLC

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 1265606198 NPI number — CLASSIC MASSAGE CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLASSIC MASSAGE CLINIC, PLLC
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:
1265606198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1627 W MAIN ST
Provider Second Line Business Mailing Address:
PMB#111
Provider Business Mailing Address City Name:
BOZEMAN
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59715-4011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-923-5938
Provider Business Mailing Address Fax Number:
360-563-0243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 AVE D
Provider Second Line Business Practice Location Address:
SUITE D-205
Provider Business Practice Location Address City Name:
SNOHOMISH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-217-8467
Provider Business Practice Location Address Fax Number:
360-217-7092
Provider Enumeration Date:
04/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LAFFERTY
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, OFFICER
Authorized Official Telephone Number:
360-563-0209

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00013819 , 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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