=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487287223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY PLACE MASSAGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2020
-----------------------------------------------------
Last Update Date | 02/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3318 BRIDGEPORT WAY W STE D2
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98466-4598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-330-9461
-----------------------------------------------------
Fax | 253-565-2322
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3318 BRIDGEPORT WAY W STE D2
-----------------------------------------------------
City | UNIVERSITY PLACE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98466-4598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-330-9461
-----------------------------------------------------
Fax | 253-566-2322
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JOELLE DEREMIAH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-330-9461
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------