Provider Demographics
NPI:1518542786
Name:KAMBACK, KRYSTAL
Entity Type:Individual
Prefix:MISS
First Name:KRYSTAL
Middle Name:
Last Name:KAMBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 25TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1605
Mailing Address - Country:US
Mailing Address - Phone:760-793-8495
Mailing Address - Fax:
Practice Address - Street 1:1246 25TH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1605
Practice Address - Country:US
Practice Address - Phone:760-793-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24982225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty