Provider Demographics
NPI:1124464326
Name:STILL LIFE MASSAGE AND FLOAT
Entity type:Organization
Organization Name:STILL LIFE MASSAGE AND FLOAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:C
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-647-2805
Mailing Address - Street 1:19 BELLWETHER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2966
Mailing Address - Country:US
Mailing Address - Phone:360-647-2805
Mailing Address - Fax:360-734-4148
Practice Address - Street 1:19 BELLWETHER WAY STE 101
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2966
Practice Address - Country:US
Practice Address - Phone:360-647-2805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017027225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1194853036OtherPERSONAL NPI