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General NPI Number Information
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NPI Number | 1114053790
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Entity Type | Organization
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Legal Business Name | SERENE LAKE MASSAGE THERAPY
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Dates
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Enumeration Date | 02/26/2007
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Last Update Date | 07/21/2008
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Provider Practice Location Address
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Address Line | 5521 186TH PL SW
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City | LYNNWOOD
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State | WA
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Zip | 98037-4325
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Country | US
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Telephone | 425-776-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 5521 186TH PL SW
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City | LYNNWOOD
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State | WA
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Zip | 98037-4325
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Country | US
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Telephone | 425-776-3000
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CHAD ERIC TRIPLETT
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Credential | LMP
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Telephone | 425-776-3000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MA000010193
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License Number State | WA
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