MEDICARE: NATHAN IDROGO LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	18349	OR

General Provider Information

NPI Number	:	1134995954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN IDROGO LMT

Provider Business Mailing Address
First Line	:	7551 CRATER LAKE HWY STE B
Second Line	:
City	:	WHITE CITY
State	:	OR
Zip	:	97503-1670
Country	:	US
Telephone Number	:	541-601-1708
Fax Number	:

Provider Business Practice Location Address
First Line	:	7551 CRATER LAKE HWY STE B
Second Line	:
City	:	WHITE CITY
State	:	OR
Zip	:	97503-1670
Country	:	US
Telephone Number	:	541-601-1708
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2023
Last Update Date	:	12/01/2023

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