Provider Demographics
NPI:1265838098
Name:MD THERAPY & MASSAGE LLC
Entity Type:Organization
Organization Name:MD THERAPY & MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-908-7559
Mailing Address - Street 1:14113 SE 177TH ST APT J305
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-9251
Mailing Address - Country:US
Mailing Address - Phone:360-908-7559
Mailing Address - Fax:
Practice Address - Street 1:5401 6TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2618
Practice Address - Country:US
Practice Address - Phone:360-908-7559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60298052225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty