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General NPI Number Information
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NPI Number | 1659798437
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Entity Type | Organization
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Legal Business Name | SELF BALANCE MASSAGE
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Dates
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Enumeration Date | 03/18/2014
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Last Update Date | 03/18/2014
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Provider Practice Location Address
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Address Line | 5107 NE 94TH AVE STE A
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City | VANCOUVER
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State | WA
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Zip | 98662-6188
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Country | US
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Telephone | 360-202-7085
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Fax | 801-501-7085
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Provider Business Mailing Address
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Address Line | 5107 NE 94TH AVE STE A
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City | VANCOUVER
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State | WA
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Zip | 98662-6188
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Country | US
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Telephone | 360-202-7085
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Fax | 801-501-7085
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Authorized Official
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Title or Position | CO-OWNER
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Name | TERESA L BONAWITZ
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Credential | LMP
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Telephone | 360-202-7085
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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 | MA60042214
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License Number State | WA
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