=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578016788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED MASSAGE BY ANDREA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2016
-----------------------------------------------------
Last Update Date | 07/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2031 SE BELMONT ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-325-4234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2031 SE BELMONT ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-325-4234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREA MENDIVIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-890-4711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 19676
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------