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General NPI Number Information
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NPI Number | 1811302607
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Entity Type | Organization
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Legal Business Name | PERFORMANCE BODYWORK LLC
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Dates
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Enumeration Date | 07/01/2014
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Last Update Date | 07/25/2024
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Provider Practice Location Address
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Address Line | 2188 SW PARK PL SUITE 10
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City | PORTLAND
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State | OR
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Zip | 97205-1100
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Country | US
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Telephone | 503-568-1390
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Fax |
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Provider Business Mailing Address
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Address Line | 2188 SW PARK PL SUITE 10
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City | PORTLAND
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State | OR
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Zip | 97205-1100
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Country | US
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Telephone | 503-568-1390
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CASEY HOLLIMAN
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Credential | LMT
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Telephone | 503-568-1390
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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