Healthcare Provider Details

I. General information

NPI: 1699915983
Provider Name (Legal Business Name): MARY ANN KOVACS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 10/25/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4475 SW SCHOLLS FERRY RD STE 201
PORTLAND OR
97225-1955
US

IV. Provider business mailing address

P.O. BOX 1393
RAPID CITY SD
57709
US

V. Phone/Fax

Practice location:
  • Phone: 503-246-2350
  • Fax:
Mailing address:
  • Phone: 605-348-2357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12771
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR057393
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: