Provider Demographics
NPI:1003332255
Name:BACK TO FORM STRUCTURAL STRENGTH AND MASSAGE
Entity Type:Organization
Organization Name:BACK TO FORM STRUCTURAL STRENGTH AND MASSAGE
Other - Org Name:PNW MASSAGE & SPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/LMP
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VANDENBOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:206-383-3186
Mailing Address - Street 1:509 OLIVE WAY STE 851
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1769
Mailing Address - Country:US
Mailing Address - Phone:206-383-3186
Mailing Address - Fax:206-397-3458
Practice Address - Street 1:509 OLIVE WAY STE 851
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1769
Practice Address - Country:US
Practice Address - Phone:206-383-3186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60255380225700000X
WAMA60546268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty