Provider Demographics
NPI:1144574096
Name:BLOOMING MOON WELLNESS SPA INC.
Entity Type:Organization
Organization Name:BLOOMING MOON WELLNESS SPA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND ESTHETICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TOUSIGNANT
Authorized Official - Suffix:
Authorized Official - Credentials:ESTHETICIAN COS-FT
Authorized Official - Phone:971-279-2757
Mailing Address - Street 1:1920 N KILLINGSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4437
Mailing Address - Country:US
Mailing Address - Phone:971-279-2757
Mailing Address - Fax:
Practice Address - Street 1:1920 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4437
Practice Address - Country:US
Practice Address - Phone:971-279-2757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR69864495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty