Provider Demographics
NPI:1407368293
Name:JADE VINE MASSAGE
Entity Type:Organization
Organization Name:JADE VINE MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:CAMILLA
Authorized Official - Last Name:NUSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:907-394-8645
Mailing Address - Street 1:1413 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-6646
Mailing Address - Country:US
Mailing Address - Phone:907-394-8345
Mailing Address - Fax:907-283-5350
Practice Address - Street 1:43335 KALIFORNSKY BEACH RD STE 25
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-8280
Practice Address - Country:US
Practice Address - Phone:907-394-8345
Practice Address - Fax:907-283-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK121821225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty