Provider Demographics
NPI:1356672216
Name:BONNEY LAKE CLINICAL MASSAGE LLC
Entity Type:Organization
Organization Name:BONNEY LAKE CLINICAL MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-862-4441
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-0757
Mailing Address - Country:US
Mailing Address - Phone:253-862-4441
Mailing Address - Fax:
Practice Address - Street 1:21157 STATE ROUTE 410 E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8457
Practice Address - Country:US
Practice Address - Phone:253-862-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty