=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851887962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT SMITH LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2018
-----------------------------------------------------
Last Update Date | 07/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 NW 23RD AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97210-2557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-223-8719
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2437 SE TAYLOR ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-2869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-660-5310
-----------------------------------------------------
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 | 23828
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------