Provider Demographics
NPI:1225364458
Name:AVALON SPA
Entity type:Organization
Organization Name:AVALON SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROSENDALE
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-490-7012
Mailing Address - Street 1:670 E STRONG RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-8865
Mailing Address - Country:US
Mailing Address - Phone:360-490-7012
Mailing Address - Fax:
Practice Address - Street 1:670 E STRONG RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-8865
Practice Address - Country:US
Practice Address - Phone:360-490-7012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00014201225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty