MEDICARE: BLUE FOOT HEALING 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	:	1477302495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE FOOT HEALING LLC

Provider Business Mailing Address
First Line	:	7318 N LEAVITT AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-4840
Country	:	US
Telephone Number	:	503-567-5880
Fax Number	:	866-629-1294

Provider Business Practice Location Address
First Line	:	7318 N LEAVITT AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-4840
Country	:	US
Telephone Number	:	503-567-5880
Fax Number	:	866-629-1294

Authorized Official
Title or Position	:	FOUNDING LMT
Name	:	PAKE RYAN NIELSON
Credential	:	LMT
Telephone Number	:	503-567-5880

Provider Enumeration Date	:	05/13/2024
Last Update Date	:	03/20/2025

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