Provider Demographics
NPI:1225415250
Name:FIRESIDE MASSAGE
Entity Type:Organization
Organization Name:FIRESIDE MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENCED MASSAGE THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SKLODOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:814-932-9669
Mailing Address - Street 1:110 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:PA
Mailing Address - Zip Code:16630-1213
Mailing Address - Country:US
Mailing Address - Phone:814-932-9669
Mailing Address - Fax:
Practice Address - Street 1:110 KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:CRESSON
Practice Address - State:PA
Practice Address - Zip Code:16630-1213
Practice Address - Country:US
Practice Address - Phone:814-932-9669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG003985302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization