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General NPI Number Information
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NPI Number | 1740766328
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Entity Type | Organization
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Legal Business Name | VITALITY MASSAGE
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Dates
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Enumeration Date | 07/17/2018
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Last Update Date | 07/17/2018
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Provider Practice Location Address
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Address Line | 307 E. ROBERT BUSH DRIVE SUITE #4
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City | SOUTH BEND
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State | WA
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Zip | 98586-9858
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Country | US
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Telephone | 360-942-7956
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 246
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City | SOUTH BEND
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State | WA
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Zip | 98586-0246
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Country | US
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Telephone | 360-942-7956
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Fax | 360-934-5357
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Authorized Official
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Title or Position | THERAPIST
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Name | AMY D TRIPLETT
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Credential | LMP
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Telephone | 360-942-7956
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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 | MA00025266
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License Number State | WA
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