Provider Demographics
NPI:1326346768
Name:KITSAP THERAPEUTIC MEDICAL MASSAGE AND BODYWORK, LLC
Entity Type:Organization
Organization Name:KITSAP THERAPEUTIC MEDICAL MASSAGE AND BODYWORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULENE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKOLAC
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-710-3299
Mailing Address - Street 1:PO BOX 4988
Mailing Address - Street 2:
Mailing Address - City:SOUTH COLBY
Mailing Address - State:WA
Mailing Address - Zip Code:98384-0988
Mailing Address - Country:US
Mailing Address - Phone:360-710-8097
Mailing Address - Fax:
Practice Address - Street 1:4275 SE MILE HILL DR
Practice Address - Street 2:SUITE B
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3934
Practice Address - Country:US
Practice Address - Phone:360-710-3299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA000020549225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty