=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538451224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABSOLUTE BALANCE BODYWORK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2011
-----------------------------------------------------
Last Update Date | 05/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 833 SE MAIN ST STE 428
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-3433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-407-9055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12570 SE 105TH AVE
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-6728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-407-9055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | MR. JOHN FRANK VARESIO
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 503-407-9055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 17597
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18132
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------