Provider Demographics
NPI:1457850653
Name:CANYON GATE MASSAGE THERAPY AND WELLNESS LLP
Entity Type:Organization
Organization Name:CANYON GATE MASSAGE THERAPY AND WELLNESS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:BREITLING
Authorized Official - Last Name:NELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:801-602-5091
Mailing Address - Street 1:1145 E 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-5401
Mailing Address - Country:US
Mailing Address - Phone:801-613-0825
Mailing Address - Fax:
Practice Address - Street 1:1145 E 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-5401
Practice Address - Country:US
Practice Address - Phone:801-613-0825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30847244701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty