Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 20031 | OR |
NPI | 1003239104 |
---|---|
Provider Name | Mr. Jackson Lee Andrews |
First Address | Powell Butte, OR 97753-1513 |
Second Address | Powell Butte, OR 97753-1513 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2014 |
Last Update Date | 24/01/2014 |