Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 25272 | OR |
NPI | 1013538875 |
---|---|
Provider Name | Elizabeth Bastidas |
First Address | Medford, OR 97501-7945 |
Second Address | Medford, OR 97501-7945 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2020 |
Last Update Date | 05/05/2020 |