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General NPI Number Information
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NPI Number | 1255852117
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Entity Type | Organization
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Legal Business Name | NW MASSAGE THERAPY CORP
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Dates
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Enumeration Date | 06/30/2017
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Last Update Date | 06/30/2017
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Provider Practice Location Address
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Address Line | 16906 SE 1ST ST STE 103
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City | VANCOUVER
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State | WA
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Zip | 98684-8512
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Country | US
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Telephone | 360-903-9963
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Fax |
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Provider Business Mailing Address
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Address Line | 17413 NE 3RD ST
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City | VANCOUVER
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State | WA
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Zip | 98684-3730
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Country | US
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Telephone | 360-903-9963
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DOUGLAS BLACK
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Credential | LMP
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Telephone | 360-903-9963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA00011374
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License Number State |
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