Provider Demographics
NPI:1003785841
Name:GREEN WELLNESS MASSAGE LLC
Entity type:Organization
Organization Name:GREEN WELLNESS MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:717-838-2600
Mailing Address - Street 1:PO BOX 494
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17010-0494
Mailing Address - Country:US
Mailing Address - Phone:717-838-2600
Mailing Address - Fax:
Practice Address - Street 1:2855 HORSESHOE PIKE
Practice Address - Street 2:
Practice Address - City:CAMPBELLTOWN
Practice Address - State:PA
Practice Address - Zip Code:17010
Practice Address - Country:US
Practice Address - Phone:717-838-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health