=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790240414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROMNICK DANCEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2019
-----------------------------------------------------
Last Update Date | 02/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 MONROE PKWY STE U
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-8875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-387-3205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14038 SE UPPER ALDERCREST DR
-----------------------------------------------------
City | MILWAUKIE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97267-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 24668
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------