Provider Demographics
NPI:1649547126
Name:KEYSAR CENTER OF MASSAGE FOR THE MEDICALLY FRAGILE
Entity type:Organization
Organization Name:KEYSAR CENTER OF MASSAGE FOR THE MEDICALLY FRAGILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KACI
Authorized Official - Middle Name:J
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:206-724-5393
Mailing Address - Street 1:500 W MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4252
Mailing Address - Country:US
Mailing Address - Phone:360-623-1214
Mailing Address - Fax:360-623-1215
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4252
Practice Address - Country:US
Practice Address - Phone:360-623-1214
Practice Address - Fax:360-623-1215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60156485174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60156485OtherINTRA ORAL