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General NPI Number Information
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NPI Number | 1689969966
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Entity Type | Organization
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Legal Business Name | EAGLE RIVER THERAPEUTIC MASSAGE LLC
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Dates
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Enumeration Date | 06/14/2011
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Last Update Date | 06/14/2011
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Provider Practice Location Address
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Address Line | 10421 VFW RD SUITE 101
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City | EAGLE RIVER
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State | AK
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Zip | 99577-8032
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Country | US
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Telephone | 907-351-7191
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Fax | 907-622-4001
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Provider Business Mailing Address
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Address Line | 24712 TEAL LOOP
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City | CHUGIAK
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State | AK
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Zip | 99567-5114
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Country | US
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Telephone | 907-351-7191
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Fax | 907-622-4001
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | MRS. JEANETTE STACK
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Credential | LMP, NCTMB
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Telephone | 907-351-7191
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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 | MA00014238
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License Number State | WA
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