MEDICARE: THERAPEUTIC INTEGRATIVE MASSAGE & EXERCISE, 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	247200000X	Other Technician	7084	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7084	OTHER	OR	MASSAGE LICENSE

General Provider Information

NPI Number	:	1184838518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPEUTIC INTEGRATIVE MASSAGE & EXERCISE, LLC

Provider Business Mailing Address
First Line	:	2604 SW 64TH PL
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97225-8168
Country	:	US
Telephone Number	:	503-709-1568
Fax Number	:	503-709-1568

Provider Business Practice Location Address
First Line	:	9860 SW HALL BLVD STE A
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-8896
Country	:	US
Telephone Number	:	503-709-1568
Fax Number	:

Authorized Official
Title or Position	:	ORGANIZER
Name	:	TERESA JOANNE ALLEN
Credential	:	LMT
Telephone Number	:	503-709-1568

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	08/22/2020

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