Provider Demographics
NPI:1962266874
Name:RANGER DISIABLED INJURY MASSAGE LLC
Entity type:Organization
Organization Name:RANGER DISIABLED INJURY MASSAGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEBEDIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDES
Authorized Official - Suffix:
Authorized Official - Credentials:MASSAGE THERAPIST
Authorized Official - Phone:360-949-0133
Mailing Address - Street 1:4414 NE 115TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-4479
Mailing Address - Country:US
Mailing Address - Phone:503-739-3565
Mailing Address - Fax:
Practice Address - Street 1:14010 NE 3RD CT BLDG B
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2928
Practice Address - Country:US
Practice Address - Phone:360-949-0133
Practice Address - Fax:360-768-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty