MEDICARE: HAVEN STONE 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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13000	OTHER	OR	OREGON BOARD OF MASSAGE THERAPY

General Provider Information

NPI Number	:	1427561182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVEN STONE MASSAGE

Provider Business Mailing Address
First Line	:	215 W ILLINOIS ST
Second Line	:
City	:	NEWBERG
State	:	OR
Zip	:	97132-1607
Country	:	US
Telephone Number	:	503-430-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1530 E 1ST ST
Second Line	:
City	:	NEWBERG
State	:	OR
Zip	:	97132-3237
Country	:	US
Telephone Number	:	503-430-4200
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HILARY VANESSA BRAMLEY
Credential	:	LMT
Telephone Number	:	503-430-4200

Provider Enumeration Date	:	11/15/2017
Last Update Date	:	11/15/2017

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Directions to “HAVEN STONE MASSAGE ” Practice Location

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