Provider Demographics
NPI:1750749800
Name:WILD IRIS INTEGRATIVE MASSAGE LLC
Entity type:Organization
Organization Name:WILD IRIS INTEGRATIVE MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LAWTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:907-746-3270
Mailing Address - Street 1:1865 N KENTUCKY DERBY DR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8836
Mailing Address - Country:US
Mailing Address - Phone:907-746-3270
Mailing Address - Fax:
Practice Address - Street 1:810 S COLONY WAY
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6980
Practice Address - Country:US
Practice Address - Phone:907-746-3270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty