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General NPI Number Information
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NPI Number | 1588371439
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Entity Type | Organization
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Legal Business Name | BAMBOO GARDEN ONE LLC
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Dates
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Enumeration Date | 10/31/2022
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Last Update Date | 10/31/2022
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Provider Practice Location Address
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Address Line | 651 HIGH ST NE STE 110
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City | SALEM
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State | OR
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Zip | 97301-2490
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Country | US
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Telephone | 503-689-6658
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Fax | 971-423-0378
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Provider Business Mailing Address
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Address Line | 620 36TH AVE NE
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City | SALEM
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State | OR
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Zip | 97301-4740
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Country | US
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Telephone | 503-689-6658
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Fax | 971-423-0378
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Authorized Official
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Title or Position | OWNER
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Name | MR. SUNG LI
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Credential | LMT
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Telephone | 503-689-6658
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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 |
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License Number State |
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