Provider Demographics
NPI:1790096931
Name:RELAXATION STATION
Entity Type:Organization
Organization Name:RELAXATION STATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TEDDY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRANDON
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:269-668-7770
Mailing Address - Street 1:23701 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9701
Mailing Address - Country:US
Mailing Address - Phone:269-668-7770
Mailing Address - Fax:269-668-7770
Practice Address - Street 1:23701 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9701
Practice Address - Country:US
Practice Address - Phone:269-668-7770
Practice Address - Fax:269-668-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001223261QM1300X
IN31001489A261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty