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General NPI Number Information
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NPI Number | 1497359350
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Entity Type | Organization
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Legal Business Name | MASSAGE RESTORATION LLC
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Dates
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Enumeration Date | 11/22/2020
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Last Update Date | 11/22/2020
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Provider Practice Location Address
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Address Line | 4520 INTELCO LOOP SE BLDG 3
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City | LACEY
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State | WA
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Zip | 98503-6008
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Country | US
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Telephone | 360-388-0485
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Fax | 360-890-4066
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Provider Business Mailing Address
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Address Line | 9649 LOOKOUT DR NW
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City | OLYMPIA
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State | WA
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Zip | 98502-9757
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Country | US
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Telephone | 360-388-0485
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Fax | 360-890-4066
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Authorized Official
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Title or Position | OWNER
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Name | JACLYN JUNE MONGE SOUTHARD
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Credential | LMT
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Telephone | 360-388-0485
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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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