Provider Demographics
NPI:1689091605
Name:INDIGO FOUNTAIN MASSAGE
Entity Type:Organization
Organization Name:INDIGO FOUNTAIN MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANTHEA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAY
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-731-8665
Mailing Address - Street 1:3656 NW MUNSON ST
Mailing Address - Street 2:#1
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9140
Mailing Address - Country:US
Mailing Address - Phone:360-731-8665
Mailing Address - Fax:
Practice Address - Street 1:3656 NW MUNSON ST
Practice Address - Street 2:#1
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9140
Practice Address - Country:US
Practice Address - Phone:360-731-8665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602851131225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty