Basic Information
| Provider Information | |||||||||
| NPI: | 1861870347 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STANDLEY LAKE MASSAGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8725 WADSWORTH BLVD | ||||||||
| Address2: | UNIT A | ||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800030928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034257298 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8725 WADSWORTH BLVD | ||||||||
| Address2: | UNIT A | ||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800030928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034257298 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2015 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | GARG | ||||||||
| AuthorizedOfficialFirstName: | PANKAJ | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7203331589 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | MT0013340 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.