Provider Demographics
NPI:1518573179
Name:DRAGONFLY MEDICAL MASSAGE STUDIO LLC
Entity Type:Organization
Organization Name:DRAGONFLY MEDICAL MASSAGE STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERICA
Authorized Official - Middle Name:LENNARTZ
Authorized Official - Last Name:MORTIMER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:509-961-8314
Mailing Address - Street 1:3003 W VIOLA AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4939
Mailing Address - Country:US
Mailing Address - Phone:509-961-8314
Mailing Address - Fax:509-588-7916
Practice Address - Street 1:3405 W NOB HILL BLVD STE A
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4732
Practice Address - Country:US
Practice Address - Phone:509-961-8314
Practice Address - Fax:509-588-7916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA61018816OtherMASSAGE THERAPY