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General NPI Number Information
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NPI Number | 1528417243
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Entity Type | Organization
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Legal Business Name | ALASKA THERAPEUTIC MASSAGE LLC
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Dates
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Enumeration Date | 06/03/2016
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Last Update Date | 06/03/2016
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Provider Practice Location Address
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Address Line | 418 WEDGEWOOD DR
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City | FAIRBANKS
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State | AK
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Zip | 99701-1604
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Country | US
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Telephone | 907-347-4580
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 74058
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City | FAIRBANKS
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State | AK
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Zip | 99707-4058
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | RACHELLE EBBESSON
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Credential |
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Telephone | 907-347-4580
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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 | 101581
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License Number State | AK
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