Provider Demographics
NPI:1578956637
Name:COUNTRY CLINICAL MASSAGE
Entity Type:Organization
Organization Name:COUNTRY CLINICAL MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SMEDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:208-755-6301
Mailing Address - Street 1:PO BOX 1015
Mailing Address - Street 2:6101 E HWY 54 SUITE A
Mailing Address - City:ATHOL
Mailing Address - State:ID
Mailing Address - Zip Code:83801-1015
Mailing Address - Country:US
Mailing Address - Phone:208-755-6301
Mailing Address - Fax:
Practice Address - Street 1:6101 E HIGHWAY 54 STE A
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-6085
Practice Address - Country:US
Practice Address - Phone:208-755-6301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-47225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty