Provider Demographics
NPI:1427698299
Name:LAKE WASHINGTON MASSAGE AND WELLNESS LLC
Entity type:Organization
Organization Name:LAKE WASHINGTON MASSAGE AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-275-9005
Mailing Address - Street 1:15965 NE 85TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3593
Mailing Address - Country:US
Mailing Address - Phone:425-882-9065
Mailing Address - Fax:
Practice Address - Street 1:15965 NE 85TH ST STE 102
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3593
Practice Address - Country:US
Practice Address - Phone:425-882-9065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty