=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821525056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHEYENNE LEE VAZQUEZ LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2017
-----------------------------------------------------
Last Update Date | 05/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 NE 7TH ST
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-1634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-244-8208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2820 REDWOOD AVE
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97527-6338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-244-8208
-----------------------------------------------------
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 | 20834
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------