Provider Demographics
NPI:1164926374
Name:AT VANCOUVER MASSAGE, LLC
Entity Type:Organization
Organization Name:AT VANCOUVER MASSAGE, LLC
Other - Org Name:AT VANCOUVER MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KONCOS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:360-635-3477
Mailing Address - Street 1:204 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3409
Mailing Address - Country:US
Mailing Address - Phone:360-635-3477
Mailing Address - Fax:
Practice Address - Street 1:1508 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3434
Practice Address - Country:US
Practice Address - Phone:360-635-3477
Practice Address - Fax:844-682-7291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019183225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty