MEDICARE: CLAIRE VALLA 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	4915	OR

General Provider Information

NPI Number	:	1164971271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLAIRE VALLA LMT

Provider Business Mailing Address
First Line	:	6726 SE BROOKLYN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-1951
Country	:	US
Telephone Number	:	503-913-9224
Fax Number	:

Provider Business Practice Location Address
First Line	:	6726 SE BROOKLYN ST
Second Line	:	67
City	:	PORTLAND
State	:	OR
Zip	:	97206-1951
Country	:	US
Telephone Number	:	503-913-9224
Fax Number	:

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

Provider Enumeration Date	:	09/30/2016
Last Update Date	:	09/30/2016

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