=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841515947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPA BLISS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2010
-----------------------------------------------------
Last Update Date | 03/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 NE 8TH ST
-----------------------------------------------------
City | MCMINNVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97128-4002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-883-4929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 NE 8TH ST
-----------------------------------------------------
City | MCMINNVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97128-4002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-883-4929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MARY R. REED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-883-4929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | COS-FA-10122642
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------