1518153378 NPI number — MASSAGE RADIANCE

Table of content: (NPI 1518153378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518153378 NPI number — MASSAGE RADIANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASSAGE RADIANCE
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:
1518153378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2420 E MEADOW BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98273-2374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-540-1900
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2108 RIVERSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273-5406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-540-1900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PALMER
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
360-540-1900

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  MA00024680 , 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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