Provider Demographics
NPI:1285934810
Name:AMBIANCE MASSAGE & SPA, LTD
Entity type:Organization
Organization Name:AMBIANCE MASSAGE & SPA, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHOPE
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:360-537-5914
Mailing Address - Street 1:PO BOX 1244
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-0246
Mailing Address - Country:US
Mailing Address - Phone:360-537-5914
Mailing Address - Fax:360-532-1059
Practice Address - Street 1:501 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-3924
Practice Address - Country:US
Practice Address - Phone:360-537-5914
Practice Address - Fax:360-532-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019187225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty