Provider Demographics
NPI:1316247331
Name:SUNRIDGE MASSAGE THERAPY LLC
Entity type:Organization
Organization Name:SUNRIDGE MASSAGE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:304-573-9817
Mailing Address - Street 1:PO BOX 389
Mailing Address - Street 2:
Mailing Address - City:BOLT
Mailing Address - State:WV
Mailing Address - Zip Code:25817-0389
Mailing Address - Country:US
Mailing Address - Phone:304-573-9817
Mailing Address - Fax:
Practice Address - Street 1:102 GUYAN DRIVE
Practice Address - Street 2:
Practice Address - City:MACARTHUR
Practice Address - State:WV
Practice Address - Zip Code:25873-0102
Practice Address - Country:US
Practice Address - Phone:304-573-9817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2001-0739171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty