Provider Demographics
NPI:1164897120
Name:LEVIRG.INC
Entity Type:Organization
Organization Name:LEVIRG.INC
Other - Org Name:MASSAGE OFF CENTRAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:BROUILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:CMT
Authorized Official - Phone:763-333-2690
Mailing Address - Street 1:11806 ABERDEEN ST NE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4736
Mailing Address - Country:US
Mailing Address - Phone:763-333-2690
Mailing Address - Fax:
Practice Address - Street 1:11806 ABERDEEN ST NE
Practice Address - Street 2:SUITE 180
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4736
Practice Address - Country:US
Practice Address - Phone:763-333-2690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15-07259225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty