Provider Demographics
NPI:1386004208
Name:INNERGIZED MOVEMENT MASSAGE
Entity Type:Organization
Organization Name:INNERGIZED MOVEMENT MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-771-2490
Mailing Address - Street 1:1900 NE 3RD ST STE 106
Mailing Address - Street 2:MAILBOX #170
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3889
Mailing Address - Country:US
Mailing Address - Phone:541-771-2490
Mailing Address - Fax:
Practice Address - Street 1:21045 BAYOU DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2437
Practice Address - Country:US
Practice Address - Phone:541-771-2490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20452172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172M00000XOther Service ProvidersMechanotherapistGroup - Single Specialty