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General NPI Number Information
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NPI Number | 1194122754
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Entity Type | Organization
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Legal Business Name | WILLAMETTE THERAPEUTIC MASSAGE, LLC
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Dates
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Enumeration Date | 11/26/2014
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Last Update Date | 11/26/2014
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Provider Practice Location Address
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Address Line | 442 NW 3RD ST
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City | CORVALLIS
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State | OR
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Zip | 97330-6403
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Country | US
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Telephone | 541-738-7653
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Fax |
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Provider Business Mailing Address
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Address Line | 442 NW 3RD ST
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City | CORVALLIS
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State | OR
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Zip | 97330-6403
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Country | US
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Telephone | 541-738-7653
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MR. DONALD BUTZNER
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Credential | LMT
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Telephone | 541-738-7653
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 7643
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License Number State | OR
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