Provider Demographics
NPI:1124778758
Name:TLC MASSAGE AND SPA INC
Entity type:Organization
Organization Name:TLC MASSAGE AND SPA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAANGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MASSAGE THERAPIST
Authorized Official - Phone:847-207-0285
Mailing Address - Street 1:102 MINNIE ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-4385
Mailing Address - Country:US
Mailing Address - Phone:815-356-5710
Mailing Address - Fax:
Practice Address - Street 1:102 MINNIE ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4385
Practice Address - Country:US
Practice Address - Phone:815-356-5710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty