Provider Demographics
NPI:1174952964
Name:BLUE MOON MASSAGE STUDIO, LLC
Entity type:Organization
Organization Name:BLUE MOON MASSAGE STUDIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RYE
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:253-509-0258
Mailing Address - Street 1:7700 PIONEER WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1156
Mailing Address - Country:US
Mailing Address - Phone:253-509-0258
Mailing Address - Fax:
Practice Address - Street 1:7700 PIONEER WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1156
Practice Address - Country:US
Practice Address - Phone:253-509-0258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00007473171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty