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General NPI Number Information
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NPI Number | 1427447481
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Entity Type | Organization
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Legal Business Name | LAVENDERA MASSAGE LLC
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Dates
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Enumeration Date | 01/14/2015
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Last Update Date | 01/14/2015
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Provider Practice Location Address
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Address Line | 285 SPRING ST
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City | FRIDAY HARBOR
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State | WA
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Zip | 98250
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Country | US
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Telephone | 360-378-3637
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2645
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City | FRIDAY HARBOR
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State | WA
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Zip | 98250-2645
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Country | US
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Telephone | 360-378-3637
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. RICHARD A DAVENPORT
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Credential | LMP
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Telephone | 360-378-3637
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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 | MA60091736
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License Number State | WA
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