Provider Demographics
NPI:1083941082
Name:A DESTINATION MASSAGE & SPA
Entity Type:Organization
Organization Name:A DESTINATION MASSAGE & SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:DUNCAN-SARGENT
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-426-7247
Mailing Address - Street 1:PO BOX I
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-0048
Mailing Address - Country:US
Mailing Address - Phone:360-426-7247
Mailing Address - Fax:360-426-7247
Practice Address - Street 1:117 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2564
Practice Address - Country:US
Practice Address - Phone:360-427-3189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019692225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty