Provider Demographics
NPI:1790035749
Name:ISLAND THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:ISLAND THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOVALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-735-0610
Mailing Address - Street 1:6043 HUDSON RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1018
Mailing Address - Country:US
Mailing Address - Phone:612-735-0610
Mailing Address - Fax:
Practice Address - Street 1:6043 HUDSON RD
Practice Address - Street 2:SUITE 125
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1018
Practice Address - Country:US
Practice Address - Phone:612-735-0610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty