MEDICARE: GLAMRUSH BEAUTY BAR LLC

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

General Provider Information

NPI Number	:	1780388744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLAMRUSH BEAUTY BAR LLC

Provider Business Mailing Address
First Line	:	128 NE LOMBARD ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-2216
Country	:	US
Telephone Number	:	253-260-9551
Fax Number	:

Provider Business Practice Location Address
First Line	:	2225 LLOYD CTR FL 3
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1315
Country	:	US
Telephone Number	:	503-837-7368
Fax Number	:

Authorized Official
Title or Position	:	LMT
Name	:	ZUMURRUDAH RAHMAN
Credential	:
Telephone Number	:	253-260-9551

Provider Enumeration Date	:	03/27/2023
Last Update Date	:	03/27/2023

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Directions to “GLAMRUSH BEAUTY BAR LLC ” Practice Location

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