MEDICARE: MS. MARY KAY VANZANT 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	11464	OR

General Provider Information

NPI Number	:	1558579425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KAY VANZANT LMT

Provider Business Mailing Address
First Line	:	4329 SE 64TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-3629
Country	:	US
Telephone Number	:	503-772-3632
Fax Number	:

Provider Business Practice Location Address
First Line	:	5311 N VANCOUVER AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-2731
Country	:	US
Telephone Number	:	503-281-0308
Fax Number	:	503-281-4691

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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