Healthcare Provider Details

I. General information

NPI: 1760831473
Provider Name (Legal Business Name): BODY BALANCE ROLFING AND MASSAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 SW BEAVERTON HILLSDALE HWY SUITE 5
PORTLAND OR
97225-1400
US

IV. Provider business mailing address

6504 SW BOUNDARY ST
PORTLAND OR
97225-1450
US

V. Phone/Fax

Practice location:
  • Phone: 503-890-9365
  • Fax:
Mailing address:
  • Phone: 503-345-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number19379
License Number StateOR

VIII. Authorized Official

Name: JENNIFER ROCK
Title or Position: OWNER
Credential: LMT
Phone: 503-345-7660