Provider Demographics
NPI:1508641465
Name:EASTERN THERAPEUTIC LLC
Entity Type:Organization
Organization Name:EASTERN THERAPEUTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:860-800-9180
Mailing Address - Street 1:32 CORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1406
Mailing Address - Country:US
Mailing Address - Phone:860-800-9180
Mailing Address - Fax:
Practice Address - Street 1:336 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-2349
Practice Address - Country:US
Practice Address - Phone:860-800-9180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty