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General NPI Number Information
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NPI Number | 1366092132
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Entity Type | Organization
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Legal Business Name | ROOTED SPRUCE MASSAGE AND BODYWORK
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Dates
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Enumeration Date | 09/13/2019
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Last Update Date | 09/13/2019
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Provider Practice Location Address
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Address Line | 120 NE 117TH AVE RM 8
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City | VANCOUVER
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State | WA
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Zip | 98684-5020
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Country | US
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Telephone | 971-770-1360
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Fax |
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Provider Business Mailing Address
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Address Line | 120 NE 117TH AVE RM 8
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City | VANCOUVER
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State | WA
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Zip | 98684-5020
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Country | US
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Telephone | 971-770-1360
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | IMUYA LEE DOOLEY MCDANIEL
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Credential | LMT
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Telephone | 971-770-1360
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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 |
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License Number State |
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