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General NPI Number Information
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NPI Number | 1326493446
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Entity Type | Organization
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Legal Business Name | TRENT D. WILSON
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Dates
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Enumeration Date | 04/26/2016
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Last Update Date | 04/26/2016
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Provider Practice Location Address
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Address Line | 8401 NE HALSEY ST. SUITE 101
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City | PORTLAND
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State | OR
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Zip | 97220
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Country | US
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Telephone | 503-255-7000
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Fax | 503-255-7001
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Provider Business Mailing Address
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Address Line | 957 NE 110TH AVE
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City | PORTLAND
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State | OR
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Zip | 97220
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Country | US
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Telephone | 503-255-7000
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Fax | 503-255-7001
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Authorized Official
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Title or Position | LMT
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Name | MR. TRENT DANIEL WILSON
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Credential |
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Telephone | 503-255-7000
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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 | 10366
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License Number State | OR
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