Provider Demographics
NPI:1679295679
Name:MOBILE MASSAGE PRO PLLC
Entity type:Organization
Organization Name:MOBILE MASSAGE PRO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDDLE
Authorized Official - Suffix:II
Authorized Official - Credentials:LMT
Authorized Official - Phone:360-605-0680
Mailing Address - Street 1:21407 W BAKER RD
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-9160
Mailing Address - Country:US
Mailing Address - Phone:253-327-8719
Mailing Address - Fax:
Practice Address - Street 1:21407 W BAKER RD
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-9160
Practice Address - Country:US
Practice Address - Phone:253-327-8719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty