Provider Demographics
NPI:1467859447
Name:WHITE WILLOW MASSAGE
Entity Type:Organization
Organization Name:WHITE WILLOW MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMT
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-391-9693
Mailing Address - Street 1:12708 CULTIVATOR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607
Mailing Address - Country:US
Mailing Address - Phone:208-991-2298
Mailing Address - Fax:
Practice Address - Street 1:12708 CULTIVATOR ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5298
Practice Address - Country:US
Practice Address - Phone:208-991-2298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty