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General NPI Number Information
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NPI Number | 1932580255
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Entity Type | Organization
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Legal Business Name | NAUTILUS MASSAGE THERAPY BY ALYSE CONLEY
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Dates
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Enumeration Date | 06/11/2015
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Last Update Date | 06/11/2015
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Provider Practice Location Address
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Address Line | 810 E JACKSON ST STE B 810 EAST JACKSON ST SUITE B
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City | MEDFORD
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State | OR
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Zip | 97504-6773
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Country | US
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Telephone | 154-173-1137
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Fax |
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Provider Business Mailing Address
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Address Line | 810 E JACKSON ST STE B 810 EAST JACKSON ST SUITE B
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City | MEDFORD
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State | OR
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Zip | 97504-6773
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Country | US
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Telephone | 154-173-1137
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Fax |
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Authorized Official
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Title or Position | LMT
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Name | MS. MARY ALYSE CONELY
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Credential | LMT
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Telephone | 541-973-1137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 18674
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License Number State | OR
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