Healthcare Provider Details

I. General information

NPI: 1891927661
Provider Name (Legal Business Name): BODYWORK MASSAGE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 NE HOOD AVE
GRESHAM OR
97030-7449
US

IV. Provider business mailing address

329 NE HOOD AVE
GRESHAM OR
97030-7449
US

V. Phone/Fax

Practice location:
  • Phone: 503-618-9760
  • Fax:
Mailing address:
  • Phone: 503-618-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number7087
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. DAVID JONATHAN EMERSON
Title or Position: PRESIDENT
Credential: LMT
Phone: 503-618-9760