Healthcare Provider Details

I. General information

NPI: 1609082767
Provider Name (Legal Business Name): MONTESANO SPA WORKS AND MASSAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S MAIN ST
MONTESANO WA
98563-3709
US

IV. Provider business mailing address

PO BOX 828
MONTESANO WA
98563-0828
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-2097
  • Fax: 360-249-2591
Mailing address:
  • Phone: 360-249-2097
  • Fax: 360-249-2591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateWA

VIII. Authorized Official

Name: CYNTHIA KAYE JOHNSON
Title or Position: CO-OWNER
Credential: LMP
Phone: 360-249-2097