Provider Demographics
NPI:1851779763
Name:LAKESHORE MASSAGE THERAPY INC
Entity Type:Organization
Organization Name:LAKESHORE MASSAGE THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:REAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-720-0969
Mailing Address - Street 1:1845 LAKESHORE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-1896
Mailing Address - Country:US
Mailing Address - Phone:231-720-0969
Mailing Address - Fax:
Practice Address - Street 1:1845 LAKESHORE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-1896
Practice Address - Country:US
Practice Address - Phone:231-720-0969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501001486225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty