MEDICARE: MANDY MICHELLE GREGG 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	14363	OR

General Provider Information

NPI Number	:	1265602007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANDY MICHELLE GREGG LMT

Provider Business Mailing Address
First Line	:	1748 SE ELLIOTT AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4812
Country	:	US
Telephone Number	:	503-459-9331
Fax Number	:

Provider Business Practice Location Address
First Line	:	2035 SE BELMONT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-2812
Country	:	US
Telephone Number	:	503-459-9331
Fax Number	:

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

Provider Enumeration Date	:	03/07/2008
Last Update Date	:	03/07/2008

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