Provider Demographics
NPI:1558658500
Name:THREE CLOUDS ON MAIN WELLNESS CENTER & SPA
Entity Type:Organization
Organization Name:THREE CLOUDS ON MAIN WELLNESS CENTER & SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LASSITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-914-2475
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-0014
Mailing Address - Country:US
Mailing Address - Phone:541-942-2831
Mailing Address - Fax:
Practice Address - Street 1:1054 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2230
Practice Address - Country:US
Practice Address - Phone:541-942-2831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty