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General NPI Number Information
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NPI Number | 1295287068
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Entity Type | Organization
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Legal Business Name | AUTHENTIC MASSAGE THERAPY LLC
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Dates
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Enumeration Date | 10/27/2016
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Last Update Date | 10/27/2016
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Provider Practice Location Address
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Address Line | 14631 SW MILLIKAN WAY STE 14
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City | BEAVERTON
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State | OR
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Zip | 97003-2999
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Country | US
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Telephone | 312-532-3070
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Fax | 971-228-2151
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Provider Business Mailing Address
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Address Line | 14631 SW MILLIKAN WAY STE 14
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City | BEAVERTON
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State | OR
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Zip | 97003-2999
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Country | US
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Telephone | 312-532-3070
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Fax | 971-228-2151
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Authorized Official
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Title or Position | OWNER
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Name | MRS. SVETLANA Y. HOPPE
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Credential | MMP
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Telephone | 312-532-3070
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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 | 21414
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License Number State | OR
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