=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033063086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSEBURG MASSAGE HEALTH & BEAUTY SPA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2026
-----------------------------------------------------
Last Update Date | 02/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 358 SE JACKSON ST
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470-3342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-378-8399
-----------------------------------------------------
Fax | 541-637-0167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1224 NE WALNUT ST # 459
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-378-8399
-----------------------------------------------------
Fax | 541-637-0167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER/LMT
-----------------------------------------------------
Name | CRYSTALISE MOORE
-----------------------------------------------------
Credential | LMT # 21182
-----------------------------------------------------
Telephone | 541-378-8399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------