=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609256858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY THERAPY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2015
-----------------------------------------------------
Last Update Date | 06/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 CENTRAL AVE SUITE 501
-----------------------------------------------------
City | COOS BAY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97420-2272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-252-7169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 CENTRAL AVE SUITE 501
-----------------------------------------------------
City | COOS BAY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97420-2272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-252-7169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | KIMBERLY RENE GALLAGHER
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 541-252-7169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 10760
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------