Healthcare Provider Details

I. General information

NPI: 1679813646
Provider Name (Legal Business Name): ASTORIA SOJOURNER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASTORIA SOJOURNER LMT

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NE 7TH ST
GRANTS PASS OR
97526-1634
US

IV. Provider business mailing address

200 GEMINI LANE
CAVE JUNCTION OR
97523
US

V. Phone/Fax

Practice location:
  • Phone: 541-955-7246
  • Fax:
Mailing address:
  • Phone: 541-450-8958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19557
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: