Healthcare Provider Details

I. General information

NPI: 1417105248
Provider Name (Legal Business Name): SHANNON MCGINNIS-AITKEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 SE JACKSON ST
ROSEBURG OR
97470-3933
US

IV. Provider business mailing address

722 SE JACKSON ST
ROSEBURG OR
97470-3933
US

V. Phone/Fax

Practice location:
  • Phone: 541-957-2723
  • Fax:
Mailing address:
  • Phone: 541-957-2723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7925
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: