MEDICARE: JANICE MODESITT 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	1045	OR

General Provider Information

NPI Number	:	1639438419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JANICE MODESITT LMT

Provider Business Mailing Address
First Line	:	16463 BOONES FERRY RD
Second Line	:	STE. 100
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4259
Country	:	US
Telephone Number	:	503-699-2955
Fax Number	:

Provider Business Practice Location Address
First Line	:	16463 BOONES FERRY RD
Second Line	:	STE. 100
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4259
Country	:	US
Telephone Number	:	503-699-2955
Fax Number	:

Authorized Official
Title or Position	:	LICENSED MASSAGE THERAPIST
Name	:	MRS. JANICE CAROLE MODESITT
Credential	:	L.M.T.
Telephone Number	:	503-699-2955

Provider Enumeration Date	:	05/14/2012
Last Update Date	:	05/14/2012

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