=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346052321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODSTOCK MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2025
-----------------------------------------------------
Last Update Date | 02/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5835 SE LIEBE ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97206-4740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-593-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5835 SE LIEBE ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97206-4740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-593-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KUMI AKIYAMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-593-0448
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------