Provider Demographics
NPI:1578952966
Name:THE MASSAGE BOUTIQUE
Entity Type:Organization
Organization Name:THE MASSAGE BOUTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:GAPPMAYER
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:801-228-7634
Mailing Address - Street 1:12 W 100 N
Mailing Address - Street 2:202C
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003
Mailing Address - Country:US
Mailing Address - Phone:801-906-3270
Mailing Address - Fax:
Practice Address - Street 1:12 W 100 N
Practice Address - Street 2:202C
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-1611
Practice Address - Country:US
Practice Address - Phone:801-906-3270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7875506-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty