Provider Demographics
NPI:1427766328
Name:REVIVE THERAPEUTIC MASSAGE
Entity type:Organization
Organization Name:REVIVE THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:509-991-2914
Mailing Address - Street 1:707 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-7025
Mailing Address - Country:US
Mailing Address - Phone:509-991-2914
Mailing Address - Fax:
Practice Address - Street 1:707 S PARK ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-7025
Practice Address - Country:US
Practice Address - Phone:509-991-2914
Practice Address - Fax:866-629-4801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty