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General NPI Number Information
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NPI Number | 1588112676
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Entity Type | Organization
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Legal Business Name | BREATHE BODY SPA, LLC
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Dates
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Enumeration Date | 09/16/2016
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Last Update Date | 09/16/2016
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Provider Practice Location Address
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Address Line | 205 NE FORD ST
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City | MCMINNVILLE
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State | OR
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Zip | 97128-4632
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Country | US
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Telephone | 971-267-5227
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Fax |
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Provider Business Mailing Address
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Address Line | 940 SE LOCUST ST
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City | DUNDEE
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State | OR
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Zip | 97115-9630
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Country | US
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Telephone | 503-915-6021
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Fax |
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Authorized Official
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Title or Position | OWNER/LMT
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Name | MR. KELLY RYAN VAN DYKE
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Credential | LMT
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Telephone | 971-267-5227
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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 | 22338
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License Number State | OR
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