Healthcare Provider Details

I. General information

NPI: 1669053484
Provider Name (Legal Business Name): PILAR ADELINA PANGKASANK MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PILAR ADELINA PANGKASANK MASSAGE THERAPIST

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 N.E. DIVISION ST.
GRESHAM OR
97030
US

IV. Provider business mailing address

405 N.E. DIVISION ST.
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-0791
  • Fax: 503-661-1136
Mailing address:
  • Phone: 503-661-0791
  • Fax: 503-661-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number25962
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: