Provider Demographics
NPI:1417326463
Name:CLEANSING WATERS WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:CLEANSING WATERS WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:256-314-2328
Mailing Address - Street 1:1300 JOHN R ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-2255
Mailing Address - Country:US
Mailing Address - Phone:256-314-2328
Mailing Address - Fax:256-314-2328
Practice Address - Street 1:1300 JOHN R ST
Practice Address - Street 2:SUITE B
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-2255
Practice Address - Country:US
Practice Address - Phone:256-314-2328
Practice Address - Fax:256-314-2328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225500000X
AL4315225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4315OtherSTATE LICENSE