MEDICARE: RUSSIAN MASSAGE

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	19673	OR

General Provider Information

NPI Number	:	1427404466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSIAN MASSAGE

Provider Business Mailing Address
First Line	:	507 MAIN ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-6031
Country	:	US
Telephone Number	:	541-604-5753
Fax Number	:

Provider Business Practice Location Address
First Line	:	507 MAIN ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97601-6031
Country	:	US
Telephone Number	:	541-604-5753
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LMT/AMMP
Name	:	ELENA PETERS
Credential	:	LMT
Telephone Number	:	541-604-5753

Provider Enumeration Date	:	05/09/2016
Last Update Date	:	06/01/2016

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