Provider Demographics
NPI:1689969966
Name:EAGLE RIVER THERAPEUTIC MASSAGE LLC
Entity Type:Organization
Organization Name:EAGLE RIVER THERAPEUTIC MASSAGE LLC
Other - Org Name:ERTM EAGLE RIVER THERAPEUTIC MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:LMP, NCTMB
Authorized Official - Phone:907-351-7191
Mailing Address - Street 1:24712 TEAL LOOP
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-5114
Mailing Address - Country:US
Mailing Address - Phone:907-351-7191
Mailing Address - Fax:907-622-4001
Practice Address - Street 1:10421 VFW RD
Practice Address - Street 2:SUITE 101
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8032
Practice Address - Country:US
Practice Address - Phone:907-351-7191
Practice Address - Fax:907-622-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014238225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty