Healthcare Provider Details

I. General information

NPI: 1851685267
Provider Name (Legal Business Name): SAMANTHA KREIZENBECK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20630 SW VIENNA DR
ALOHA OR
97007-4115
US

IV. Provider business mailing address

20630 SW VIENNA DR
ALOHA OR
97007-4115
US

V. Phone/Fax

Practice location:
  • Phone: 503-464-6410
  • Fax:
Mailing address:
  • Phone: 503-464-6410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16765
License Number StateOR

VIII. Authorized Official

Name: SAMANTHA KREIZENBECK
Title or Position: MASSAGE THERAPIST
Credential:
Phone: 503-464-6410