Provider Demographics
NPI:1225706120
Name:EQUILIBRIUM MASSAGE THERAPY
Entity Type:Organization
Organization Name:EQUILIBRIUM MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNELLA
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:208-215-4594
Mailing Address - Street 1:PO BOX 2226
Mailing Address - Street 2:
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-2226
Mailing Address - Country:US
Mailing Address - Phone:208-215-4594
Mailing Address - Fax:
Practice Address - Street 1:118 N 7TH ST STE B8
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2704
Practice Address - Country:US
Practice Address - Phone:208-215-4594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty