Provider Demographics
NPI:1316061351
Name:CUSTOMCARE MASSAGE, P.S., INC
Entity type:Organization
Organization Name:CUSTOMCARE MASSAGE, P.S., INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:MONTEGNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-374-2600
Mailing Address - Street 1:8390 W GAGE BLVD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-8105
Mailing Address - Country:US
Mailing Address - Phone:509-374-2600
Mailing Address - Fax:888-814-3542
Practice Address - Street 1:8390 W GAGE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8105
Practice Address - Country:US
Practice Address - Phone:509-374-2600
Practice Address - Fax:888-814-3542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0164297OtherLABOR AND INDUSTRIES
WA239007239006OtherAWHN