Provider Demographics
NPI:1518153378
Name:MASSAGE RADIANCE
Entity Type:Organization
Organization Name:MASSAGE RADIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-540-1900
Mailing Address - Street 1:2420 E MEADOW BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-2374
Mailing Address - Country:US
Mailing Address - Phone:360-540-1900
Mailing Address - Fax:
Practice Address - Street 1:2108 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5406
Practice Address - Country:US
Practice Address - Phone:360-540-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024680261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center