Healthcare Provider Details

I. General information

NPI: 1992904429
Provider Name (Legal Business Name): MIA N DEANE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIA N HULIN LMT

II. Dates (important events)

Enumeration Date: 07/14/2007
Last Update Date: 07/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 CRATER LAKE AVE STE. G
MEDFORD OR
97504-6213
US

IV. Provider business mailing address

2408 BELL CT
MEDFORD OR
97504-1752
US

V. Phone/Fax

Practice location:
  • Phone: 541-857-4540
  • Fax:
Mailing address:
  • Phone: 541-261-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13269
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: