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General NPI Number Information
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NPI Number | 1386137248
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Entity Type | Organization
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Legal Business Name | ROGUE MASSAGE CLINIC, LLC
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Dates
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Enumeration Date | 06/14/2018
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 3550 NATIONAL DRIVE
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City | MEDFORD
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State | OR
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Zip | 97504
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Country | US
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Telephone | 541-324-4179
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Fax | 541-879-3025
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Provider Business Mailing Address
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Address Line | 3550 NATIONAL DRIVE
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City | MEDFORD
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State | OR
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Zip | 97504
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Country | US
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Telephone | 541-324-4179
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Fax | 541-879-3025
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MAKENZIE LAUREN HAY
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Credential | LMT
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Telephone | 541-324-4179
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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 | 21580
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License Number State | OR
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