Provider Demographics
NPI:1750759585
Name:NORTHWEST THERAPEUTIC MASSAGE
Entity type:Organization
Organization Name:NORTHWEST THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNS
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:253-564-5828
Mailing Address - Street 1:4113 BRIDGEPORT WAY W
Mailing Address - Street 2:SUITE B
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4113 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE B
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4325
Practice Address - Country:US
Practice Address - Phone:253-564-5828
Practice Address - Fax:253-564-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022176225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty