Provider Demographics
NPI:1225741994
Name:MANDALA MASSAGE
Entity Type:Organization
Organization Name:MANDALA MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-761-8262
Mailing Address - Street 1:4080 AZALEA DR
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-8297
Mailing Address - Country:US
Mailing Address - Phone:541-761-8262
Mailing Address - Fax:
Practice Address - Street 1:215 SE 6TH ST STE 207
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2471
Practice Address - Country:US
Practice Address - Phone:541-761-8262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty