Provider Demographics
NPI:1528417243
Name:ALASKA THERAPEUTIC MASSAGE LLC
Entity Type:Organization
Organization Name:ALASKA THERAPEUTIC MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBBESSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-347-4580
Mailing Address - Street 1:PO BOX 74058
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-4058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:418 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-1604
Practice Address - Country:US
Practice Address - Phone:907-347-4580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101581225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty