Provider Demographics
NPI:1407100639
Name:THERAPEUTIC MASSAGE & BODYWORK LLC
Entity Type:Organization
Organization Name:THERAPEUTIC MASSAGE & BODYWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:801-687-3957
Mailing Address - Street 1:904 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3560
Mailing Address - Country:US
Mailing Address - Phone:801-687-3957
Mailing Address - Fax:
Practice Address - Street 1:904 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3560
Practice Address - Country:US
Practice Address - Phone:801-687-3957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5370898-1202111N00000X
UT6077621-4701225700000X
UT8407908-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty