Provider Demographics
NPI:1740694066
Name:PURE MASSAGE BOULDER LLC.
Entity type:Organization
Organization Name:PURE MASSAGE BOULDER LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS-HAIMANN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:303-909-5480
Mailing Address - Street 1:3656 PINEDALE ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3711
Mailing Address - Country:US
Mailing Address - Phone:303-909-5480
Mailing Address - Fax:
Practice Address - Street 1:1280 YELLOW PINE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-2264
Practice Address - Country:US
Practice Address - Phone:303-909-5480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO225700000XOtherMASSAGE THERAPIST