Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 20149 | OR |
NPI | 1003287897 |
---|---|
Provider Name | Roger Twitchell |
First Address | Portland, OR 97202-1510 |
Second Address | Portland, OR 97202-1510 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2015 |
Last Update Date | 19/10/2015 |