Provider Demographics
NPI:1730233669
Name:REJUVENATION OF BALLARD
Entity type:Organization
Organization Name:REJUVENATION OF BALLARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:206-778-0063
Mailing Address - Street 1:4775 BALLARD AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4810
Mailing Address - Country:US
Mailing Address - Phone:206-778-0063
Mailing Address - Fax:206-297-0838
Practice Address - Street 1:4775 BALLARD AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4810
Practice Address - Country:US
Practice Address - Phone:206-778-0063
Practice Address - Fax:206-297-0838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00014583225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty