MEDICARE: RESTORE MASSAGE THERAPY, INC

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	11539	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	225700000X	OTHER	OR	MASSAGE THERAPIST

General Provider Information

NPI Number	:	1720481518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORE MASSAGE THERAPY, INC

Provider Business Mailing Address
First Line	:	1922 21ST AVE
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1638
Country	:	US
Telephone Number	:	503-701-7714
Fax Number	:

Provider Business Practice Location Address
First Line	:	1922 21ST AVE
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1638
Country	:	US
Telephone Number	:	503-701-7714
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ MASSAGE THERAPIST
Name	:	MELINDA GRACE APODACA
Credential	:	LMT
Telephone Number	:	503-701-7714

Provider Enumeration Date	:	10/07/2014
Last Update Date	:	10/07/2014

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Directions to “RESTORE MASSAGE THERAPY, INC ” Practice Location

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