Provider Demographics
NPI:1619280724
Name:ATLANTIS THERAPEUTIC MASSAGE LLC
Entity Type:Organization
Organization Name:ATLANTIS THERAPEUTIC MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:860-429-8106
Mailing Address - Street 1:PO BOX 694
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-0694
Mailing Address - Country:US
Mailing Address - Phone:860-429-8106
Mailing Address - Fax:
Practice Address - Street 1:46 KING HILL RD
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-1759
Practice Address - Country:US
Practice Address - Phone:860-429-8106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-17
Last Update Date:2010-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002104225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty