Provider Demographics
NPI:1164850913
Name:BAYFIELD MASSAGE
Entity Type:Organization
Organization Name:BAYFIELD MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:G
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-884-2455
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122-0622
Mailing Address - Country:US
Mailing Address - Phone:970-884-2455
Mailing Address - Fax:
Practice Address - Street 1:40031 US HIGHWAY 160
Practice Address - Street 2:SUITE C
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122-8746
Practice Address - Country:US
Practice Address - Phone:970-884-2455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0011270174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty