Provider Demographics
NPI:1093042186
Name:CAROL ROSE MASSAGE LLC
Entity Type:Organization
Organization Name:CAROL ROSE MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:MATHRE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-440-3664
Mailing Address - Street 1:41991 MEYER LN
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8428
Mailing Address - Country:US
Mailing Address - Phone:503-440-3664
Mailing Address - Fax:
Practice Address - Street 1:1154 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4126
Practice Address - Country:US
Practice Address - Phone:503-440-3664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-10
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11681225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty