MEDICARE: ELIZABETH ELLEN JOHN L.M.T.

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	10349	OR

General Provider Information

NPI Number	:	1770687824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ELLEN JOHN L.M.T.

Provider Business Mailing Address
First Line	:	2534 SE SALMON ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-3948
Country	:	US
Telephone Number	:	503-484-7432
Fax Number	:

Provider Business Practice Location Address
First Line	:	1016 SE 12TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-2513
Country	:	US
Telephone Number	:	503-484-7432
Fax Number	:

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

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	07/08/2007

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