Healthcare Provider Details

I. General information

NPI: 1679766109
Provider Name (Legal Business Name): GEORGIA RENAE LOOSIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14017 N NEWPORT HWY STE C
MEAD WA
99021-9203
US

IV. Provider business mailing address

14017 N NEWPORT HWY STE C
MEAD WA
99021-9203
US

V. Phone/Fax

Practice location:
  • Phone: 509-939-1761
  • Fax:
Mailing address:
  • Phone: 509-939-1761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00023633
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: