Healthcare Provider Details

I. General information

NPI: 1881379360
Provider Name (Legal Business Name): TIKISHLA MEDICAL MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 06/21/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E. 57TH PLACE ANCHORAGE
ANCHORAGE AK
99518
US

IV. Provider business mailing address

3927 REFLECTION DR
ANCHORAGE AK
99504-4385
US

V. Phone/Fax

Practice location:
  • Phone: 907-602-3137
  • Fax:
Mailing address:
  • Phone: 907-602-3137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAREN WITTHOEFT
Title or Position: CO-OWNER
Credential: LMT
Phone: 907-602-3137