Provider Demographics
NPI:1346786894
Name:SEA SPA STEILACOOM
Entity Type:Organization
Organization Name:SEA SPA STEILACOOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-620-2016
Mailing Address - Street 1:215 WILKES ST
Mailing Address - Street 2:#104
Mailing Address - City:STEILACOOM
Mailing Address - State:WA
Mailing Address - Zip Code:98388-2125
Mailing Address - Country:US
Mailing Address - Phone:253-248-7888
Mailing Address - Fax:
Practice Address - Street 1:215 WILKES ST
Practice Address - Street 2:#104
Practice Address - City:STEILACOOM
Practice Address - State:WA
Practice Address - Zip Code:98388-2125
Practice Address - Country:US
Practice Address - Phone:253-248-7888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty