Provider Demographics
NPI:1154709145
Name:SAMARRA MASSAGE
Entity type:Organization
Organization Name:SAMARRA MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMARRA
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:585-278-8402
Mailing Address - Street 1:1815 ROCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:NY
Mailing Address - Zip Code:14485-9501
Mailing Address - Country:US
Mailing Address - Phone:585-278-8402
Mailing Address - Fax:
Practice Address - Street 1:1344 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1656
Practice Address - Country:US
Practice Address - Phone:585-278-8402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025579225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty