MEDICARE: MICHAEL IAN GILL LAC

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	7888	OR

General Provider Information

NPI Number	:	1093055840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL IAN GILL LAC

Provider Business Mailing Address
First Line	:	1020 SE 7TH AVE
Second Line	:	15248
City	:	PORTLAND
State	:	OR
Zip	:	97293-0856
Country	:	US
Telephone Number	:	971-279-3591
Fax Number	:

Provider Business Practice Location Address
First Line	:	124 SW YAMHILL ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97204-3019
Country	:	US
Telephone Number	:	971-279-3591
Fax Number	:

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

Provider Enumeration Date	:	02/14/2013
Last Update Date	:	02/14/2013

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