Provider Demographics
NPI:1003117441
Name:DEFIANCE THERAPEUTIC MASSAGE & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:DEFIANCE THERAPEUTIC MASSAGE & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RADZIK
Authorized Official - Suffix:
Authorized Official - Credentials:ATC, LMT
Authorized Official - Phone:419-497-2112
Mailing Address - Street 1:8081 ADAMS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512
Mailing Address - Country:US
Mailing Address - Phone:419-497-2112
Mailing Address - Fax:419-497-2114
Practice Address - Street 1:8081 ADAMS RIDGE RD
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-9173
Practice Address - Country:US
Practice Address - Phone:419-497-2112
Practice Address - Fax:419-497-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65.000157171100000X
OH33.014099174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty