Healthcare Provider Details

I. General information

NPI: 1295182848
Provider Name (Legal Business Name): GRESHAM THERAPEUTIC MASSAGE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 NW FAIRVIEW DR
GRESHAM OR
97030-3842
US

IV. Provider business mailing address

1748 NW FAIRVIEW DR
GRESHAM OR
97030-3842
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-3910
  • Fax: 503-674-6706
Mailing address:
  • Phone: 503-492-3910
  • Fax: 503-674-6706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number21991
License Number StateOR

VIII. Authorized Official

Name: HEATHER HOARD
Title or Position: OWNER
Credential:
Phone: 503-492-3910