Provider Demographics
NPI:1811553852
Name:POPLAR CREEK SPA, LLC
Entity type:Organization
Organization Name:POPLAR CREEK SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:423-238-5775
Mailing Address - Street 1:5906 MAIN ST STE 140
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-9297
Mailing Address - Country:US
Mailing Address - Phone:423-238-5775
Mailing Address - Fax:423-961-8113
Practice Address - Street 1:5906 MAIN ST STE 140
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-9297
Practice Address - Country:US
Practice Address - Phone:423-238-5775
Practice Address - Fax:423-961-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1649687146Medicaid