Provider Demographics
NPI:1255038295
Name:FERN & FAE MASSAGE
Entity type:Organization
Organization Name:FERN & FAE MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/LMT
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:360-313-6465
Mailing Address - Street 1:100 E 19TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3385
Mailing Address - Country:US
Mailing Address - Phone:360-313-6465
Mailing Address - Fax:
Practice Address - Street 1:100 E 19TH ST STE 500
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3385
Practice Address - Country:US
Practice Address - Phone:360-313-6465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty