Healthcare Provider Details

I. General information

NPI: 1841545837
Provider Name (Legal Business Name): GRESHAM BALANCE BODY WORKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST
GRESHAM OR
97030
US

IV. Provider business mailing address

22400 SE STARK ST
GRESHAM OR
97030-2656
US

V. Phone/Fax

Practice location:
  • Phone: 541-510-8476
  • Fax: 503-907-0098
Mailing address:
  • Phone: 541-510-8476
  • Fax: 503-907-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13478
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1962678755
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNPI TYPE 1

VIII. Authorized Official

Name: LINDSAY LINDALA
Title or Position: OWNER
Credential:
Phone: 541-510-8476