Healthcare Provider Details

I. General information

NPI: 1083470298
Provider Name (Legal Business Name): NICOLE C TABER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 CHIEF MIWALETA LN
CANYONVILLE OR
97417-9700
US

IV. Provider business mailing address

152 NW BREE DR
WINSTON OR
97496-9550
US

V. Phone/Fax

Practice location:
  • Phone: 541-839-1111
  • Fax:
Mailing address:
  • Phone: 541-606-0532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19670
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: