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General NPI Number Information
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NPI Number | 1407368293
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Entity Type | Organization
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Legal Business Name | JADE VINE MASSAGE
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Dates
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Enumeration Date | 11/01/2017
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Last Update Date | 11/01/2017
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Provider Practice Location Address
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Address Line | 43335 KALIFORNSKY BEACH RD STE 25
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City | SOLDOTNA
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State | AK
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Zip | 99669-8280
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Country | US
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Telephone | 907-394-8345
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Fax | 907-283-5350
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Provider Business Mailing Address
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Address Line | 1413 COURTNEY DR
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City | KENAI
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State | AK
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Zip | 99611-6646
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Country | US
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Telephone | 907-394-8345
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Fax | 907-283-5350
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Authorized Official
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Title or Position | OWNER
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Name | HANNAH CAMILLA NUSBAUM
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Credential | LMT
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Telephone | 907-394-8645
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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 | 121821
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License Number State | AK
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