Provider Demographics
NPI:1013947787
Name:AVALON MASSAGE & DAY SPA LTD
Entity Type:Organization
Organization Name:AVALON MASSAGE & DAY SPA LTD
Other - Org Name:MINDY'S MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-582-9977
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:CARLSBORG
Mailing Address - State:WA
Mailing Address - Zip Code:98324
Mailing Address - Country:US
Mailing Address - Phone:360-582-9977
Mailing Address - Fax:360-582-9972
Practice Address - Street 1:660 W EVERGREEN FARM WAY
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-5097
Practice Address - Country:US
Practice Address - Phone:360-582-9977
Practice Address - Fax:360-582-9972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009684225700000X
WA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA157675Medicaid
WA204592204592OtherPREMENA BC
WAW15428OtherREGENCE