=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164068490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARE KATNER LLC DBA EAST BRIDGE MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2019
-----------------------------------------------------
Last Update Date | 11/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2311 E BURNSIDE ST STE 100
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-1655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-314-9297
-----------------------------------------------------
Fax | 971-319-2195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2311 E BURNSIDE ST STE 100
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-1655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-314-9297
-----------------------------------------------------
Fax | 971-319-2195
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC MANAGER
-----------------------------------------------------
Name | WENDI SHARP
-----------------------------------------------------
Credential | MSOL
-----------------------------------------------------
Telephone | 971-263-4492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------