Provider Demographics
NPI:1093244642
Name:REPARE MASSAGE LLC
Entity Type:Organization
Organization Name:REPARE MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-679-6881
Mailing Address - Street 1:4004 SW KELLY AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4389
Mailing Address - Country:US
Mailing Address - Phone:503-679-6881
Mailing Address - Fax:
Practice Address - Street 1:4004 SW KELLY AVE STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4389
Practice Address - Country:US
Practice Address - Phone:503-679-6881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8052302R00000X
302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
542966745OtherSS