Provider Demographics
NPI:1538838461
Name:JUST KNEAD MASSAGE LLC
Entity type:Organization
Organization Name:JUST KNEAD MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LUCKOW
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:920-901-8044
Mailing Address - Street 1:5827 LUCKOW LN
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-9555
Mailing Address - Country:US
Mailing Address - Phone:920-901-8044
Mailing Address - Fax:
Practice Address - Street 1:210 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4606
Practice Address - Country:US
Practice Address - Phone:920-901-8044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI601661-11OtherNCBTMB