=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225741994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANDALA MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2022
-----------------------------------------------------
Last Update Date | 12/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 SE 6TH ST STE 207
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-2471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-761-8262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4080 AZALEA DR
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-8297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-761-8262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TANYA SUZANNE ALLEN
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 541-761-8262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------