Provider Demographics
NPI:1356859540
Name:GLISTEN TANNING SPA & SALON, LLC
Entity Type:Organization
Organization Name:GLISTEN TANNING SPA & SALON, LLC
Other - Org Name:GLISTEN TANNING SPA & SALON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, LMP
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:509-895-7383
Mailing Address - Street 1:PO BOX 8051
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-0051
Mailing Address - Country:US
Mailing Address - Phone:509-469-1903
Mailing Address - Fax:509-469-1905
Practice Address - Street 1:5603 SUMMITVIEW AVE STE 100
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3018
Practice Address - Country:US
Practice Address - Phone:509-895-7383
Practice Address - Fax:509-895-7739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60523229225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA604042951OtherUBI