Provider Demographics
NPI:1477850659
Name:SUMMERLIN MASSAGENV, LLC
Entity Type:Organization
Organization Name:SUMMERLIN MASSAGENV, LLC
Other - Org Name:MASSAGE ENVY OF BOCA PARK
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-212-3689
Mailing Address - Street 1:8950 W CHARLESTON BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5475
Mailing Address - Country:US
Mailing Address - Phone:702-212-3689
Mailing Address - Fax:
Practice Address - Street 1:8950 W CHARLESTON BLVD STE 7
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5475
Practice Address - Country:US
Practice Address - Phone:702-212-3689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT 4434225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty