Provider Demographics
NPI:1184014110
Name:HEALING TRADITIONS BODYWORK, LLC
Entity Type:Organization
Organization Name:HEALING TRADITIONS BODYWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:720-244-7217
Mailing Address - Street 1:28186 HIGHWAY 74
Mailing Address - Street 2:UNIT 7
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-5775
Mailing Address - Country:US
Mailing Address - Phone:720-244-7217
Mailing Address - Fax:
Practice Address - Street 1:26085 AMY CIR
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-6113
Practice Address - Country:US
Practice Address - Phone:720-244-7217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0004270225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty