Healthcare Provider Details

I. General information

NPI: 1790800563
Provider Name (Legal Business Name): CORIE WAITE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 ROYAL AVE
MEDFORD OR
97504-6140
US

IV. Provider business mailing address

3474 LONE PINE RD
MEDFORD OR
97504-5635
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-8331
  • Fax: 541-779-0217
Mailing address:
  • Phone: 541-301-0697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11297
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: