Healthcare Provider Details

I. General information

NPI: 1508000191
Provider Name (Legal Business Name): MASSAGE & BANYA SPA OF SANTA FE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 RODEO RD STE C14
SANTA FE NM
87507-6503
US

IV. Provider business mailing address

2801 RODEO RD STE C14
SANTA FE NM
87507-6503
US

V. Phone/Fax

Practice location:
  • Phone: 505-474-4222
  • Fax:
Mailing address:
  • Phone: 505-474-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT3231
License Number StateNM

VIII. Authorized Official

Name: KELLEY MICHELLE KOEHLER
Title or Position: OWNER
Credential: LMT
Phone: 505-474-4222