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General NPI Number Information
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NPI Number | 1366085250
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Entity Type | Organization
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Legal Business Name | ADVANCED MYOTHERAPY
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Dates
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Enumeration Date | 10/23/2019
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Last Update Date | 10/23/2019
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Provider Practice Location Address
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Address Line | 279 LIBERTY ST
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City | ASHLAND
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State | OR
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Zip | 97520-2901
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Country | US
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Telephone | 541-482-0413
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Fax |
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Provider Business Mailing Address
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Address Line | 1467 SISKIYOU BLVD # 53
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City | ASHLAND
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State | OR
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Zip | 97520-2336
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Country | US
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Telephone | 541-482-0413
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Fax | 541-482-0413
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JOSEPH MICKETTI
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Credential | LMT
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Telephone | 541-482-0413
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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 |
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License Number State |
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