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General NPI Number Information
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NPI Number | 1609267996
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Entity Type | Organization
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Legal Business Name | ORENCO MASSAGE STUDIO LLC
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Dates
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Enumeration Date | 02/09/2015
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Last Update Date | 02/09/2015
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Provider Practice Location Address
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Address Line | 1915 NW AMBERGLEN PKWY SUITE #400
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City | BEAVERTON
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State | OR
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Zip | 97006-6951
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Country | US
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Telephone | 360-910-1840
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Fax |
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Provider Business Mailing Address
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Address Line | 5841 NE ORENCO GARDENS DR
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City | HILLSBORO
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State | OR
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Zip | 97124-5128
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Country | US
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Telephone | 360-910-1840
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/SECRETARY
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Name | MR. GERALD STANLEY WILK JR.
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Credential | LMP, LMT, MBA
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Telephone | 360-910-1840
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | LMT#6259
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License Number State | OR
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