Provider Demographics
NPI:1750516084
Name:WAI PAIN MANAGEMENT MASSAGE THERAPY
Entity type:Organization
Organization Name:WAI PAIN MANAGEMENT MASSAGE THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIT
Authorized Official - Prefix:MS
Authorized Official - First Name:WAI
Authorized Official - Middle Name:MUN
Authorized Official - Last Name:AU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-255-4039
Mailing Address - Street 1:1231 CHESTNUT ST # 128
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4105
Mailing Address - Country:US
Mailing Address - Phone:267-255-4039
Mailing Address - Fax:215-829-0499
Practice Address - Street 1:934 ARCH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-3107
Practice Address - Country:US
Practice Address - Phone:267-255-4039
Practice Address - Fax:215-829-0499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAI PAIN MANAGEMENT MASSAGE THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-15
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207881225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1750516084OtherKEYSTONE HEALTH PLEN EAST
PA1750516084OtherKEYSTONE MARCY
PA1750516084OtherMOUNTAIN STATE BCBS
PA1750516084Medicaid
PA1750516084OtherUNIFORM MEDICAL PLAN- HARRINGTON
PA1750516084OtherINDEPENDENCE BLUE CROSS BLUE SHIELD
PA1750516084OtherAMERIHEALTH
PA1750516084OtherAETNA
PA1750516084OtherHIGHMARK BLUE CROSS BLUE SHIELD
PA1750516084OtherCIGNA
PA1750516084OtherCIGNA
PA1750516084Medicare PIN
PA1750516084Medicaid