Provider Demographics
NPI:1962803999
Name:WATERSTONE SPA
Entity type:Organization
Organization Name:WATERSTONE SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPA MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEB
Authorized Official - Middle Name:
Authorized Official - Last Name:CLELAND
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-488-0325
Mailing Address - Street 1:236 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1831
Mailing Address - Country:US
Mailing Address - Phone:541-488-0325
Mailing Address - Fax:
Practice Address - Street 1:236 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1831
Practice Address - Country:US
Practice Address - Phone:541-488-0325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK ANTONY HISTORIC PROPERTY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15742225700000X
OR4717225700000X
OR19945225700000X
OR7830225700000X
OR3271225700000X
OR10040225700000X
OR13277225700000X
OR14949225700000X
OR9081225700000X
OR7728225700000X
OR14893225700000X
OR20191225700000X
OR12260225700000X
OR13700225700000X
OR16600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty