MEDICARE: CANNON BEACH SPA INC

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	261QP2000X	Physical Therapy Clinic/Center	1458	OR

General Provider Information

NPI Number	:	1134383920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANNON BEACH SPA INC

Provider Business Mailing Address
First Line	:	PO BOX 953
Second Line	:
City	:	CANNON BEACH
State	:	OR
Zip	:	97110-0953
Country	:	US
Telephone Number	:	503-436-8772
Fax Number	:

Provider Business Practice Location Address
First Line	:	232 N SPRUCE ST
Second Line	:
City	:	CANNON BEACH
State	:	OR
Zip	:	97110
Country	:	US
Telephone Number	:	503-436-8772
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TIMOTHY J KRUPA
Credential	:	DC
Telephone Number	:	503-436-8772

Provider Enumeration Date	:	07/11/2008
Last Update Date	:	07/11/2008

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Directions to “CANNON BEACH SPA INC ” Practice Location

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