Provider Demographics
NPI:1104535814
Name:MASSAGE EVOLUTION LLC
Entity type:Organization
Organization Name:MASSAGE EVOLUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HACKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:920-737-3452
Mailing Address - Street 1:2615 PACKERLAND DR STE F1
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5780
Mailing Address - Country:US
Mailing Address - Phone:920-288-1235
Mailing Address - Fax:
Practice Address - Street 1:2615 PACKERLAND DR STE F1
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5780
Practice Address - Country:US
Practice Address - Phone:920-288-1235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service