Healthcare Provider Details

I. General information

NPI: 1649707175
Provider Name (Legal Business Name): DIANE DEYULIA MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 SW 15TH ST UNIT 47
BEND OR
97702-1058
US

IV. Provider business mailing address

PO BOX 342
BEND OR
97709-0342
US

V. Phone/Fax

Practice location:
  • Phone: 541-508-6581
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number20245
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: