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General NPI Number Information
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NPI Number | 1790140994
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Entity Type | Organization
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Legal Business Name | GAYLORD CLINICAL MASSAGE
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Dates
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Enumeration Date | 12/15/2015
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Last Update Date | 12/15/2015
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Provider Practice Location Address
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Address Line | 111 W MITCHELL ST
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City | GAYLORD
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State | MI
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Zip | 49735-1481
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Country | US
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Telephone | 989-732-3626
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Fax |
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Provider Business Mailing Address
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Address Line | 111 W MITCHELL ST
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City | GAYLORD
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State | MI
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Zip | 49735-1481
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Country | US
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Telephone | 989-732-3626
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRICIA MARIE OROURKE
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Credential | CMT, LMT
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Telephone | 989-732-3626
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 7501002044
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License Number State | MI
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