Provider Demographics
NPI:1063124196
Name:MASSAGE GROTTOSF LLC
Entity type:Organization
Organization Name:MASSAGE GROTTOSF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER; LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:CMT
Authorized Official - Phone:808-937-4342
Mailing Address - Street 1:544 CHURCH ST APT 307
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2052
Mailing Address - Country:US
Mailing Address - Phone:808-937-4342
Mailing Address - Fax:
Practice Address - Street 1:4333 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1376
Practice Address - Country:US
Practice Address - Phone:415-234-3236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty