Provider Demographics
NPI:1154063832
Name:STRUCTURAL SYNERGY LLC
Entity Type:Organization
Organization Name:STRUCTURAL SYNERGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:STAR
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:505-402-1885
Mailing Address - Street 1:50 MAIN ST STE 206-3
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-6758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 MAIN ST STE 206-3
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-6758
Practice Address - Country:US
Practice Address - Phone:505-402-1885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty