Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 20583 | OR |
NPI | 1003201286 |
---|---|
Provider Name | Mr. Jason Rambo |
First Address | Grants Pass, OR 97526-2010 |
Second Address | Grants Pass, OR 97526-2010 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2015 |
Last Update Date | 03/04/2015 |