Provider Demographics
NPI:1497359350
Name:MASSAGE RESTORATION LLC
Entity Type:Organization
Organization Name:MASSAGE RESTORATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:JUNE MONGE
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:360-388-0485
Mailing Address - Street 1:9649 LOOKOUT DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9757
Mailing Address - Country:US
Mailing Address - Phone:360-388-0485
Mailing Address - Fax:360-890-4066
Practice Address - Street 1:4520 INTELCO LOOP SE BLDG 3
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6008
Practice Address - Country:US
Practice Address - Phone:360-388-0485
Practice Address - Fax:360-890-4066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty