Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | LMT#4132 | OR |
NPI | 1003172412 |
---|---|
Provider Name | Chung So |
First Address | Vancouver, WA 98665-8511 |
Second Address | Portland, OR 97202-5715 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2012 |
Last Update Date | 10/04/2012 |