Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 24629 | OR |
NPI | 1003461153 |
---|---|
Provider Name | Riley Mitchell |
First Address | Salem, OR 97302-4609 |
Second Address | Salem, OR 97302 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/08/2019 |
Last Update Date | 06/08/2019 |