Provider Demographics
NPI:1033975545
Name:SODA CITY THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:SODA CITY THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMT
Authorized Official - Phone:719-205-6605
Mailing Address - Street 1:120 BENT OAK TRL
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-8380
Mailing Address - Country:US
Mailing Address - Phone:719-205-6605
Mailing Address - Fax:
Practice Address - Street 1:300 BERKSHIRE DR STE C
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1859
Practice Address - Country:US
Practice Address - Phone:803-906-0301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty