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General NPI Number Information
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NPI Number | 1427404466
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Entity Type | Organization
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Legal Business Name | RUSSIAN MASSAGE
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Dates
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Enumeration Date | 05/09/2016
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Last Update Date | 06/01/2016
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Provider Practice Location Address
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Address Line | 507 MAIN ST
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City | KLAMATH FALLS
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State | OR
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Zip | 97601-6031
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Country | US
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Telephone | 541-604-5753
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Fax |
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Provider Business Mailing Address
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Address Line | 507 MAIN ST
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City | KLAMATH FALLS
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State | OR
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Zip | 97601-6031
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Country | US
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Telephone | 541-604-5753
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Fax |
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Authorized Official
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Title or Position | OWNER/LMT/AMMP
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Name | ELENA PETERS
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Credential | LMT
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Telephone | 541-604-5753
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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 | 19673
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License Number State | OR
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