Provider Demographics
NPI:1740766328
Name:VITALITY MASSAGE
Entity type:Organization
Organization Name:VITALITY MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRIPLETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-942-7956
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98586-0246
Mailing Address - Country:US
Mailing Address - Phone:360-942-7956
Mailing Address - Fax:360-934-5357
Practice Address - Street 1:307 E. ROBERT BUSH DRIVE SUITE #4
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98586-9858
Practice Address - Country:US
Practice Address - Phone:360-942-7956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00025266225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1497928055OtherPROVIDER