Healthcare Provider Details

I. General information

NPI: 1710355599
Provider Name (Legal Business Name): QUIET RIVER MASSAGE & BODYWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 N WASHINGTON AVE
PRESCOTT AZ
86301-3206
US

IV. Provider business mailing address

132 N WASHINGTON AVE
PRESCOTT AZ
86301-3206
US

V. Phone/Fax

Practice location:
  • Phone: 928-273-6897
  • Fax:
Mailing address:
  • Phone: 928-273-6897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberMT-11435
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMT-11435
License Number StateAZ

VIII. Authorized Official

Name: MRS. LUCY HELEN COREY
Title or Position: MANUAL THERAPIST
Credential: LMT NCMT
Phone: 928-273-6897