=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154984060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARRIOR WITHIN WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2019
-----------------------------------------------------
Last Update Date | 04/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3863 SW HALL BLVD STE B
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-482-4499
-----------------------------------------------------
Fax | 503-214-8790
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3863 SW HALL BLVD STE B
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97005-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-482-4499
-----------------------------------------------------
Fax | 503-214-8790
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MADDY CHAVEZ
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 503-482-4499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------