Provider Demographics
NPI:1376387654
Name:PURE LIFE MASSAGE THERAPY AND SPA
Entity type:Organization
Organization Name:PURE LIFE MASSAGE THERAPY AND SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LATOYIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VINES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:334-463-9391
Mailing Address - Street 1:9306 VERDIN CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-8823
Mailing Address - Country:US
Mailing Address - Phone:334-294-5456
Mailing Address - Fax:334-649-1077
Practice Address - Street 1:8437 CROSSLAND LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-8485
Practice Address - Country:US
Practice Address - Phone:334-463-9391
Practice Address - Fax:334-649-1077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-21
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty