MEDICARE: GRAPE STREET MASSAGE 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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1477148740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAPE STREET MASSAGE LLC

Provider Business Mailing Address
First Line	:	782 COLUMBINE WAY
Second Line	:
City	:	CENTRAL POINT
State	:	OR
Zip	:	97502-4802
Country	:	US
Telephone Number	:	541-261-8625
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 S GRAPE ST
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97501-3147
Country	:	US
Telephone Number	:	541-261-8628
Fax Number	:	938-888-7262

Authorized Official
Title or Position	:	OWNER, LICENSED MASSAGE THERAPIST
Name	:	SAMANTHA K SHORKEY
Credential	:
Telephone Number	:	541-261-8628

Provider Enumeration Date	:	03/08/2021
Last Update Date	:	03/08/2021

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Directions to “GRAPE STREET MASSAGE LLC ” Practice Location

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