=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104336791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODY REFLECTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2017
-----------------------------------------------------
Last Update Date | 10/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1631 15TH AVE W STE 308
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98119-2796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-679-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1631 15TH AVE W STE 308
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98119-2796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-679-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CARLIE BAE
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 206-679-0111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA00022371
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------