Healthcare Provider Details

I. General information

NPI: 1740830579
Provider Name (Legal Business Name): LILY ANDERSON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2214 NE MCDONALD LN
MCMINNVILLE OR
97128-2702
US

IV. Provider business mailing address

2214 NE MCDONALD LN
MCMINNVILLE OR
97128-2702
US

V. Phone/Fax

Practice location:
  • Phone: 503-434-6603
  • Fax: 503-434-6746
Mailing address:
  • Phone: 503-434-6603
  • Fax: 503-434-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number25387
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: