Healthcare Provider Details

I. General information

NPI: 1265944532
Provider Name (Legal Business Name): MARIA LUCIA BUZOLLO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 A ST STE 3
ASHLAND OR
97520-1970
US

IV. Provider business mailing address

155 STRAWBERRY LN
ASHLAND OR
97520-2758
US

V. Phone/Fax

Practice location:
  • Phone: 907-351-7993
  • Fax:
Mailing address:
  • Phone: 907-351-7993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number106322
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: