Healthcare Provider Details

I. General information

NPI: 1609277276
Provider Name (Legal Business Name): RORRI HENSTOCK L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MAIN ST
BUHL ID
83316-1236
US

IV. Provider business mailing address

2305 E 2200 N
TWIN FALLS ID
83301-0628
US

V. Phone/Fax

Practice location:
  • Phone: 208-543-2005
  • Fax:
Mailing address:
  • Phone: 208-329-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-241
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: