Provider Demographics
NPI:1972039717
Name:KNEADED MEDICAL MASSAGE LLC
Entity Type:Organization
Organization Name:KNEADED MEDICAL MASSAGE LLC
Other - Org Name:MEDICAL MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:COBURN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:304-952-1692
Mailing Address - Street 1:PO BOX 586
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-0586
Mailing Address - Country:US
Mailing Address - Phone:304-256-1111
Mailing Address - Fax:304-256-1113
Practice Address - Street 1:167 DRY HILL RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2603
Practice Address - Country:US
Practice Address - Phone:304-256-1111
Practice Address - Fax:304-256-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2014-3267225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty