=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689456857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LET GO IN THE COUNTRY MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2023
-----------------------------------------------------
Last Update Date | 10/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41745 NW WILKESBORO RD
-----------------------------------------------------
City | BANKS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97106-8114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-481-6079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14520 NW SELLERS RD
-----------------------------------------------------
City | BANKS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97106-7102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 150-348-1607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KATHRYN LEE FITZPATRICK
-----------------------------------------------------
Credential | MASSAGE THERAPIST
-----------------------------------------------------
Telephone | 503-481-6079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------