Provider Demographics
NPI:1528415502
Name:KELLYS HEALING MASSAGE
Entity Type:Organization
Organization Name:KELLYS HEALING MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-994-8497
Mailing Address - Street 1:3772 HWY231
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:WA
Mailing Address - Zip Code:99173
Mailing Address - Country:US
Mailing Address - Phone:509-994-8497
Mailing Address - Fax:
Practice Address - Street 1:3772 HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:WA
Practice Address - Zip Code:99173-7008
Practice Address - Country:US
Practice Address - Phone:509-994-8497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization