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General NPI Number Information
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NPI Number | 1669919981
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Entity Type | Individual
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Provider Name | JESSE TRISTAN SLATER AAS
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Gender | Male
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Dates
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Enumeration Date | 01/24/2017
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Last Update Date | 01/24/2017
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Provider Practice Location Address
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Address Line | 816 NW HILL ST
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City | BEND
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State | OR
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Zip | 97703-2925
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Country | US
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Telephone | 541-280-7234
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Fax |
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Provider Business Mailing Address
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Address Line | 18973 BAKER RD
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City | BEND
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State | OR
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Zip | 97702-7917
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Country | US
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Telephone | 541-280-7234
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 22002
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License Number State | OR
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