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General NPI Number Information
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NPI Number | 1982924841
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Entity Type | Organization
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Legal Business Name | NYSTROM THERAPUTIC MASSAGE
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Dates
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Enumeration Date | 06/02/2010
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Last Update Date | 05/24/2013
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Provider Practice Location Address
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Address Line | 9900 SW WILSHIRE ST STE 190-E
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City | PORTLAND
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State | OR
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Zip | 97225-5035
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Country | US
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Telephone | 503-756-9076
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Fax | 503-297-3827
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Provider Business Mailing Address
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Address Line | 9900 SW WILSHIRE ST STE 190-E
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City | PORTLAND
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State | OR
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Zip | 97225-5035
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Country | US
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Telephone | 503-756-9076
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Fax | 503-297-3827
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Authorized Official
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Title or Position | OWNER
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Name | MR. YARLEY NYSTROM
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Credential | L.M.T.
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Telephone | 503-756-9076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 11353
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License Number State | OR
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