Healthcare Provider Details

I. General information

NPI: 1932878006
Provider Name (Legal Business Name): HAZEL DELL MASSAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8605 NE HIGHWAY 99 STE 108
VANCOUVER WA
98665-8921
US

IV. Provider business mailing address

8605 NE HIGHWAY 99 STE 108
VANCOUVER WA
98665-8921
US

V. Phone/Fax

Practice location:
  • Phone: 360-258-1856
  • Fax:
Mailing address:
  • Phone: 360-258-1856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. YOUNGYUN KIM
Title or Position: OWNER
Credential: DC
Phone: 253-227-8900