Provider Demographics
NPI:1649572207
Name:PURE SERENITY MASSAGE LLC
Entity Type:Organization
Organization Name:PURE SERENITY MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:DIAN
Authorized Official - Last Name:MIXER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:971-203-3632
Mailing Address - Street 1:440 COLUMBIA BLVD.
Mailing Address - Street 2:
Mailing Address - City:ST. HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051
Mailing Address - Country:US
Mailing Address - Phone:503-366-8084
Mailing Address - Fax:503-396-5936
Practice Address - Street 1:440 COLUMBIA BLVD.
Practice Address - Street 2:
Practice Address - City:ST. HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051
Practice Address - Country:US
Practice Address - Phone:503-366-8084
Practice Address - Fax:503-396-5936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PURE SERENITY MASSAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-02
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty