MEDICARE: CARLIE GABRIEL O'LEAL LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	16055	OR

General Provider Information

NPI Number	:	1043577307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLIE GABRIEL O'LEAL LMT

Provider Business Mailing Address
First Line	:	1180 SW FORESTRY LN
Second Line	:
City	:	DALLAS
State	:	OR
Zip	:	97338-9590
Country	:	US
Telephone Number	:	503-544-6649
Fax Number	:

Provider Business Practice Location Address
First Line	:	184 SE OAK ST
Second Line	:
City	:	DALLAS
State	:	OR
Zip	:	97338-1912
Country	:	US
Telephone Number	:	503-544-6649
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	04/11/2012

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