Healthcare Provider Details

I. General information

NPI: 1336786953
Provider Name (Legal Business Name): OKAERI MASSAGE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
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

2827 SE COLT DR APT 252
PORTLAND OR
97202-4493
US

V. Phone/Fax

Practice location:
  • Phone: 541-510-8476
  • Fax:
Mailing address:
  • Phone: 503-701-9409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA WALKER
Title or Position: OWNER
Credential: LMT
Phone: 503-701-9409