Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 21330 | OR |
NPI | 1013393164 |
---|---|
Provider Name | Roger Hicks |
First Address | Klamath Falls, OR 97601-2063 |
Second Address | Klamath Falls, OR 97601-6020 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2015 |
Last Update Date | 30/07/2015 |