Provider Demographics
NPI:1922525013
Name:LAVENDER AND SAGE THERAPEUTIC MASSAGE, LLC
Entity Type:Organization
Organization Name:LAVENDER AND SAGE THERAPEUTIC MASSAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:269-235-4784
Mailing Address - Street 1:2880 COLOMA RD
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022
Mailing Address - Country:US
Mailing Address - Phone:269-235-4784
Mailing Address - Fax:269-408-1993
Practice Address - Street 1:1816 WEST JOHN BEERS RD
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127
Practice Address - Country:US
Practice Address - Phone:269-235-4784
Practice Address - Fax:269-408-1993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007108225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty