Healthcare Provider Details

I. General information

NPI: 1740064849
Provider Name (Legal Business Name): MINT THAI MASSAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25326 128TH AVE SE
KENT WA
98030-6605
US

IV. Provider business mailing address

25326 128TH AVE SE
KENT WA
98030-6605
US

V. Phone/Fax

Practice location:
  • Phone: 425-502-0496
  • Fax:
Mailing address:
  • Phone: 425-502-0496
  • 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: MS. NAMFON KANPHAI
Title or Position: MASSAGE THERAPIST
Credential: LMT & MMP
Phone: 425-502-0496