Provider Demographics
NPI:1013453554
Name:FITNESS RECOVERY ROOM LLC
Entity Type:Organization
Organization Name:FITNESS RECOVERY ROOM LLC
Other - Org Name:HAWKS PRAIRIE MASSAGE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-951-4893
Mailing Address - Street 1:8830 TALLON LN NE
Mailing Address - Street 2:F
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6656
Mailing Address - Country:US
Mailing Address - Phone:360-819-2877
Mailing Address - Fax:
Practice Address - Street 1:8830 TALLON LN NE
Practice Address - Street 2:F
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6656
Practice Address - Country:US
Practice Address - Phone:360-819-2877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603440613261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center