Healthcare Provider Details

I. General information

NPI: 1316413198
Provider Name (Legal Business Name): NIKKI GROOTERS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 E 1ST AVE STE 1
SELAH WA
98942-1400
US

IV. Provider business mailing address

9 E 1ST AVE STE 1
SELAH WA
98942-1400
US

V. Phone/Fax

Practice location:
  • Phone: 509-697-4838
  • Fax: 509-697-6132
Mailing address:
  • Phone: 509-697-4838
  • Fax: 509-697-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60894285
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: