MEDICARE: KKW MASSAGE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	MA000015471	WA

General Provider Information

NPI Number	:	1255571121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KKW MASSAGE, INC

Provider Business Mailing Address
First Line	:	7904 NE 6TH AVE
Second Line	:	SUITE C
City	:	VANCOUVER
State	:	WA
Zip	:	98665-8150
Country	:	US
Telephone Number	:	360-690-4114
Fax Number	:

Provider Business Practice Location Address
First Line	:	7904 NE 6TH AVE
Second Line	:	SUITE C
City	:	VANCOUVER
State	:	WA
Zip	:	98665-8150
Country	:	US
Telephone Number	:	360-690-4114
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. KAREN K WAGNER
Credential	:
Telephone Number	:	360-690-4114

Provider Enumeration Date	:	03/04/2009
Last Update Date	:	03/04/2009

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