Healthcare Provider Details

I. General information

NPI: 1659605095
Provider Name (Legal Business Name): TRACEY ANTHONY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 NW FIRST ST SUITE 200
BEND OR
97701
US

IV. Provider business mailing address

69260 CROOKED HORSESHOE RD
SISTERS OR
97759-9602
US

V. Phone/Fax

Practice location:
  • Phone: 541-410-7320
  • Fax:
Mailing address:
  • Phone: 541-549-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13467
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: