=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447283478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUINTESSENTIAL MASSAGE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 BRYAN ST
-----------------------------------------------------
City | WENATCHEE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98801-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-664-2912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 BRYAN ST
-----------------------------------------------------
City | WENATCHEE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98801-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-664-2912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BECKY POTTORFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 509-664-2912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA00022464
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------