Healthcare Provider Details

I. General information

NPI: 1053507186
Provider Name (Legal Business Name): TERESSA S MOORE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6395 KEIZER STATION BLVD NE STE 103
KEIZER OR
97303-2305
US

IV. Provider business mailing address

14317 DUCKFLAT RD SE
TURNER OR
97392-9744
US

V. Phone/Fax

Practice location:
  • Phone: 503-589-1597
  • Fax:
Mailing address:
  • Phone: 503-884-6254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13017
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: