Provider Demographics
NPI:1265606198
Name:CLASSIC MASSAGE CLINIC, PLLC
Entity type:Organization
Organization Name:CLASSIC MASSAGE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-563-0209
Mailing Address - Street 1:1627 W MAIN ST
Mailing Address - Street 2:PMB#111
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4011
Mailing Address - Country:US
Mailing Address - Phone:425-923-5938
Mailing Address - Fax:360-563-0243
Practice Address - Street 1:1101 AVE D
Practice Address - Street 2:SUITE D-205
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290
Practice Address - Country:US
Practice Address - Phone:360-217-8467
Practice Address - Fax:360-217-7092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty