MEDICARE: MRS. JANICE CAROLE MODESITT 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	174400000X	Specialist	1035	OR

General Provider Information

NPI Number	:	1992841555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANICE CAROLE MODESITT L.M.T.

Provider Business Mailing Address
First Line	:	4299 SW COUNTRY WOODS COURT
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035
Country	:	US
Telephone Number	:	503-635-6858
Fax Number	:

Provider Business Practice Location Address
First Line	:	16463 BOONES FERRY RD
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4259
Country	:	US
Telephone Number	:	503-699-2955
Fax Number	:

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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