Provider Demographics
NPI:1710314737
Name:LIVING WELL MASSAGE THERAPY, LLC
Entity Type:Organization
Organization Name:LIVING WELL MASSAGE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-412-2165
Mailing Address - Street 1:5505 US ROUTE 60
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2070
Mailing Address - Country:US
Mailing Address - Phone:304-412-2165
Mailing Address - Fax:304-529-9237
Practice Address - Street 1:5505 US ROUTE 60
Practice Address - Street 2:SUITE 100
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2070
Practice Address - Country:US
Practice Address - Phone:304-412-2165
Practice Address - Fax:304-529-9237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1998-0144225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty