MEDICARE: CHRISTINE J SIDWELL LMT

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	173C00000X	Reflexologist	5980	OR

General Provider Information

NPI Number	:	1942585914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE J SIDWELL LMT

Provider Business Mailing Address
First Line	:	4342 NE 77TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-3922
Country	:	US
Telephone Number	:	503-232-8323
Fax Number	:

Provider Business Practice Location Address
First Line	:	4342 NE 77TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97218-3922
Country	:	US
Telephone Number	:	503-232-8323
Fax Number	:

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

Provider Enumeration Date	:	10/20/2011
Last Update Date	:	10/20/2011

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