Provider Demographics
NPI:1619365830
Name:NORTHWEST THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:NORTHWEST THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-564-5828
Mailing Address - Street 1:4113 BRIDGEPORT WAY W STE B
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4325
Mailing Address - Country:US
Mailing Address - Phone:253-564-5828
Mailing Address - Fax:253-564-0115
Practice Address - Street 1:4113 BRIDGEPORT WAY W STE B
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4325
Practice Address - Country:US
Practice Address - Phone:253-564-5828
Practice Address - Fax:253-564-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60401382174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty