Provider Demographics
NPI:1366994196
Name:BLUE LOTUS LUMINE HOLISTIC SPA
Entity type:Organization
Organization Name:BLUE LOTUS LUMINE HOLISTIC SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIUS SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:SPA OWNER MINISTRY
Authorized Official - Phone:360-259-7777
Mailing Address - Street 1:404 1ST ST S
Mailing Address - Street 2:SUITE H
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597
Mailing Address - Country:US
Mailing Address - Phone:360-955-5987
Mailing Address - Fax:360-955-5987
Practice Address - Street 1:404 1ST ST S
Practice Address - Street 2:SUITE H
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-1215
Practice Address - Country:US
Practice Address - Phone:360-955-5987
Practice Address - Fax:360-955-5987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603563570302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization