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General NPI Number Information
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NPI Number | 1538477013
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Entity Type | Organization
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Legal Business Name | MIND BODY SPIRIT LLC
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Dates
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Enumeration Date | 09/19/2010
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Last Update Date | 04/21/2014
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Provider Practice Location Address
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Address Line | 2705 E BURNSIDE ST STE 104
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City | PORTLAND
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State | OR
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Zip | 97214-1767
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Country | US
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Telephone | 503-893-4022
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Fax |
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Provider Business Mailing Address
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Address Line | 2705 E BURNSIDE ST STE 104
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City | PORTLAND
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State | OR
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Zip | 97214-1767
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Country | US
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Telephone | 503-893-4022
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JON E DARE
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Credential | LMP, LMT
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Telephone | 503-893-4022
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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 | MA60040619
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 17071
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License Number State | OR
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