Healthcare Provider Details

I. General information

NPI: 1093244642
Provider Name (Legal Business Name): REPARE MASSAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 SW KELLY AVE STE 203
PORTLAND OR
97239-4389
US

IV. Provider business mailing address

4004 SW KELLY AVE STE 203
PORTLAND OR
97239-4389
US

V. Phone/Fax

Practice location:
  • Phone: 503-679-6881
  • Fax:
Mailing address:
  • Phone: 503-679-6881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number8052
License Number StateOR

VIII. Authorized Official

Name: LESLIE JUNE CHRISTIANSEN
Title or Position: OWNER/PROVIDER
Credential: LMT
Phone: 503-679-6881