Provider Demographics
NPI:1356883227
Name:GODS LION DIVINE MASSAGE & FITNESS
Entity type:Organization
Organization Name:GODS LION DIVINE MASSAGE & FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-354-8347
Mailing Address - Street 1:5446 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3668
Mailing Address - Country:US
Mailing Address - Phone:719-354-8347
Mailing Address - Fax:719-265-5221
Practice Address - Street 1:5446 N ACADEMY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3668
Practice Address - Country:US
Practice Address - Phone:719-354-8347
Practice Address - Fax:719-265-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11350225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty