MEDICARE: MRS. IRENA ANTONOVSKA MITEV 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	13329	OR

General Provider Information

NPI Number	:	1275115248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IRENA ANTONOVSKA MITEV LMT

Provider Business Mailing Address
First Line	:	4274 NW CANARY PL
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97330-2270
Country	:	US
Telephone Number	:	541-754-2513
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 WASHINGTON ST SW
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97321-2372
Country	:	US
Telephone Number	:	760-567-9107
Fax Number	:

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

Provider Enumeration Date	:	04/28/2021
Last Update Date	:	04/28/2021

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