Provider Demographics
NPI:1730506817
Name:RIVERSIDE THERAPEUTIC MASSAGE
Entity type:Organization
Organization Name:RIVERSIDE THERAPEUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:509-946-4800
Mailing Address - Street 1:640 JADWIN AVE STE J
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4244
Mailing Address - Country:US
Mailing Address - Phone:509-946-4800
Mailing Address - Fax:509-943-1270
Practice Address - Street 1:640 JADWIN AVE STE J
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4244
Practice Address - Country:US
Practice Address - Phone:509-946-4800
Practice Address - Fax:509-943-1270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center