Provider Demographics
NPI:1033532171
Name:OREGON MASSAGE CLINIC
Entity Type:Organization
Organization Name:OREGON MASSAGE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-538-0100
Mailing Address - Street 1:408 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-2938
Mailing Address - Country:US
Mailing Address - Phone:503-538-0100
Mailing Address - Fax:971-832-8554
Practice Address - Street 1:408 E 1ST ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-2938
Practice Address - Country:US
Practice Address - Phone:503-538-0100
Practice Address - Fax:971-832-8554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16771174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty