Provider Demographics
NPI:1366965683
Name:MEDICAL MASSAGE, LLC
Entity type:Organization
Organization Name:MEDICAL MASSAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAKI
Authorized Official - Middle Name:
Authorized Official - Last Name:WADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-330-9320
Mailing Address - Street 1:2010 21ST ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-6807
Mailing Address - Country:US
Mailing Address - Phone:719-330-9320
Mailing Address - Fax:
Practice Address - Street 1:2010 21ST ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-6807
Practice Address - Country:US
Practice Address - Phone:719-330-9320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty