Provider Demographics
NPI:1699146548
Name:STILL WATERS MSSSAGE
Entity type:Organization
Organization Name:STILL WATERS MSSSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:334-343-6325
Mailing Address - Street 1:1800 W CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:OPP
Mailing Address - State:AL
Mailing Address - Zip Code:36467
Mailing Address - Country:US
Mailing Address - Phone:334-493-4357
Mailing Address - Fax:334-493-3836
Practice Address - Street 1:1800 W CUMMINGS AVE
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467
Practice Address - Country:US
Practice Address - Phone:334-493-4357
Practice Address - Fax:334-493-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2926225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1609245034OtherINDIVIDUAL NPI
AL2926OtherAL LICENSE NUMBER FOR MASSAGE