Healthcare Provider Details

I. General information

NPI: 1174388250
Provider Name (Legal Business Name): ALTA ULRICH, LMT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21707 SE STARK ST
GRESHAM OR
97030-2029
US

IV. Provider business mailing address

PO BOX 3633
GRESHAM OR
97030-0398
US

V. Phone/Fax

Practice location:
  • Phone: 503-907-0890
  • Fax:
Mailing address:
  • Phone: 503-907-0890
  • Fax: 833-638-0790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ALTA ULRICH
Title or Position: OWNER
Credential: LMT
Phone: 503-501-6312