Provider Demographics
NPI:1093593782
Name:SPA NORTHWEST LLC
Entity type:Organization
Organization Name:SPA NORTHWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:941-577-6560
Mailing Address - Street 1:5701 21ST AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5605
Mailing Address - Country:US
Mailing Address - Phone:941-713-1637
Mailing Address - Fax:
Practice Address - Street 1:5701 21ST AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5605
Practice Address - Country:US
Practice Address - Phone:941-713-1637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty