Healthcare Provider Details

I. General information

NPI: 1609781848
Provider Name (Legal Business Name): SACRED SPACE MASSAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 N DOUBLE B ST
PALMER AK
99645-5946
US

IV. Provider business mailing address

PO BOX 876214
WASILLA AK
99687-6214
US

V. Phone/Fax

Practice location:
  • Phone: 907-360-7444
  • Fax:
Mailing address:
  • Phone: 907-360-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DAWN GOOLKASIAN
Title or Position: CREDENTIALING
Credential:
Phone: 704-497-7017