Provider Demographics
NPI:1619003316
Name:SERENE LAKE MASSAGE THERAPY
Entity Type:Organization
Organization Name:SERENE LAKE MASSAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:TRIPLETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:425-745-9052
Mailing Address - Street 1:3501 SHELBY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-3599
Mailing Address - Country:US
Mailing Address - Phone:425-745-9052
Mailing Address - Fax:425-745-3372
Practice Address - Street 1:3501 SHELBY RD
Practice Address - Street 2:SUITE C
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-3599
Practice Address - Country:US
Practice Address - Phone:425-745-9052
Practice Address - Fax:425-745-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMAOOO10193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty