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General NPI Number Information
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NPI Number | 1568828614
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Entity Type | Organization
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Legal Business Name | LAKEVIEW MASSAGE THERAPY
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Dates
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Enumeration Date | 01/05/2016
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Last Update Date | 08/03/2016
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Provider Practice Location Address
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Address Line | 3498 S LAKEVIEW LOOP
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City | BIG LAKE
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State | AK
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Zip | 99652
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Country | US
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Telephone | 907-892-1628
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Fax | 907-892-1629
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Provider Business Mailing Address
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Address Line | PO BOX 521833
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City | BIG LAKE
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State | AK
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Zip | 99652-1833
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Country | US
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Telephone | 907-892-1628
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Fax | 907-892-1629
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Authorized Official
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Title or Position | OWNER/LICENSED MASSAGE THERAPIST
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Name | RENAE JEAN NELSON
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Credential | LMT
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Telephone | 907-892-1628
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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 | 1028542
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License Number State | AK
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