=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548760796
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC MARTIN VANLEEUWEN LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2018
-----------------------------------------------------
Last Update Date | 02/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2403 SE MONROE ST STE B
-----------------------------------------------------
City | MILWAUKIE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97222-7646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-303-4078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 931 SE TENINO ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-6539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-609-4343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 23759
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------