MEDICARE: REJUVEN8 MASSAGE, LLC

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	302R00000X	Health Maintenance Organization	18560	OR

General Provider Information

NPI Number	:	1093121709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REJUVEN8 MASSAGE, LLC

Provider Business Mailing Address
First Line	:	249 LIBERTY ST NE # B60
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-3503
Country	:	US
Telephone Number	:	971-273-7675
Fax Number	:

Provider Business Practice Location Address
First Line	:	388 STATE ST. NE # B60
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-3866
Country	:	US
Telephone Number	:	503-568-2854
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	BLAKE DUNHAM
Credential	:
Telephone Number	:	503-568-2854

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	09/02/2016

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Directions to “REJUVEN8 MASSAGE, LLC ” Practice Location

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