Healthcare Provider Details

I. General information

NPI: 1114322997
Provider Name (Legal Business Name): HAYDEN RASCH LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2014
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E. BURNSIDE ST. #213
PORTLAND OR
97214
US

IV. Provider business mailing address

2705 E. BURNSIDE ST. #213
PORTLAND OR
97214
US

V. Phone/Fax

Practice location:
  • Phone: 508-234-4288
  • Fax: 503-234-8613
Mailing address:
  • Phone: 508-234-4288
  • Fax: 503-234-8613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16626
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: