Provider Demographics
NPI:1427404466
Name:RUSSIAN MASSAGE
Entity Type:Organization
Organization Name:RUSSIAN MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMT/AMMP
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-604-5753
Mailing Address - Street 1:507 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6031
Mailing Address - Country:US
Mailing Address - Phone:541-604-5753
Mailing Address - Fax:
Practice Address - Street 1:507 MAIN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6031
Practice Address - Country:US
Practice Address - Phone:541-604-5753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19673225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty