MEDICARE: GLENNA MACKINNON 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	261Q00000X	Clinic/Center	5231	OR

General Provider Information

NPI Number	:	1497017396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENNA MACKINNON LMT

Provider Business Mailing Address
First Line	:	115 ELKAY DR
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97404-3060
Country	:	US
Telephone Number	:	541-525-6141
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 OAK ST
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-4022
Country	:	US
Telephone Number	:	541-525-6141
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MASSAGE THERAPIST
Name	:	GLENNA MACKINNON
Credential	:	LMT
Telephone Number	:	541-525-6141

Provider Enumeration Date	:	06/15/2012
Last Update Date	:	06/15/2012

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