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NPI Code Detail

MEDICARE: LYDIA BLAIR VAIL LMT

MEDICARE: LYDIA BLAIR VAIL 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
1225700000XMassage Therapist12753OR

General Provider Information

NPI Number : 1336332501
Entity Type Code : Individual
Provider Name (Legal Business Name) : LYDIA BLAIR VAIL LMT
Provider Business Mailing Address
First Line : 5517 N COMMERCIAL AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97217-2339
Country : US
Telephone Number : 971-404-7147
Fax Number :
Provider Business Practice Location Address
First Line : 5517 N COMMERCIAL AVE
Second Line :
City : PORTLAND
State : OR
Zip : 97217-2339
Country : US
Telephone Number : 971-404-7147
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/21/2007
Last Update Date : 08/21/2007

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Directions to “ LYDIA BLAIR VAIL LMT” Practice Location

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