Healthcare Provider Details

I. General information

NPI: 1053683813
Provider Name (Legal Business Name): BRIAN SODERHOLM LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

IV. Provider business mailing address

3536 N COMMERCIAL AVE
PORTLAND OR
97227-1308
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5555
  • Fax: 503-674-5005
Mailing address:
  • Phone: 773-701-0675
  • Fax: 503-674-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number18501
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18501
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: