1891318150 NPI number — PURE MASSAGE, LLC

Table of content: (NPI 1891318150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891318150 NPI number — PURE MASSAGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURE 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:
1891318150
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
513 N 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOURI VALLEY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51555-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-980-3657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PURE MASSAGE, LLC
Provider Second Line Business Practice Location Address:
11316 DAVENPORT ST
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-980-3657
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HEIN
Authorized Official First Name:
TERI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER/ LICENSED MASSAGE THERAPIST
Authorized Official Telephone Number:
402-980-3657

Provider Taxonomy Codes

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

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

  • Identifier: 2372 . This is a "NEBRASKA BOARD OF MASSAGE THERAPY" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 094565 . This is a "IOWA BOARD OF MASSAGE THERAPY" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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