Provider Demographics
NPI:1184838518
Name:THERAPEUTIC INTEGRATIVE MASSAGE & EXERCISE, LLC
Entity Type:Organization
Organization Name:THERAPEUTIC INTEGRATIVE MASSAGE & EXERCISE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-709-1568
Mailing Address - Street 1:2604 SW 64TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-8168
Mailing Address - Country:US
Mailing Address - Phone:503-709-1568
Mailing Address - Fax:503-709-1568
Practice Address - Street 1:9860 SW HALL BLVD STE A
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8896
Practice Address - Country:US
Practice Address - Phone:503-709-1568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7084247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7084OtherMASSAGE LICENSE