Basic Information
| Provider Information | |||||||||
| NPI: | 1366885964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COPPER MOON MASSAGE THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 COLUMBIA ST NW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603571390 | ||||||||
| FaxNumber: | 3603571391 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 COLUMBIA ST NW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603571390 | ||||||||
| FaxNumber: | 3603571391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2013 | ||||||||
| LastUpdateDate: | 04/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | KARI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/LMP | ||||||||
| AuthorizedOfficialTelephone: | 3603571390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LMP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 602443496 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.