MEDICARE: CRYSTAL MORNING SAINT ONGE 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	10004	OR

General Provider Information

NPI Number	:	1336479427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL MORNING SAINT ONGE LMT

Provider Business Mailing Address
First Line	:	2305 SE YAMHILL ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-2848
Country	:	US
Telephone Number	:	503-381-1905
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 SE 11TH AVE
Second Line	:	SUITE 221
City	:	PORTLAND
State	:	OR
Zip	:	97202-1061
Country	:	US
Telephone Number	:	503-381-1905
Fax Number	:

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

Provider Enumeration Date	:	01/12/2010
Last Update Date	:	01/12/2010

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