Healthcare Provider Details

I. General information

NPI: 1770979411
Provider Name (Legal Business Name): SPARKS MASSAGE LLC-DBA ELEMENTS MASSSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E. HASTINGS RD.
SPOKANE WA
99218
US

IV. Provider business mailing address

101 E HASTINGS RD
SPOKANE WA
99218-4901
US

V. Phone/Fax

Practice location:
  • Phone: 506-340-3303
  • Fax:
Mailing address:
  • Phone: 509-340-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60026751
License Number StateWA

VIII. Authorized Official

Name: ISIAH AARON DEAN HOWARD-MIDDLETON
Title or Position: MASSAGE THERAPIST
Credential: LMP
Phone: 509-710-5461