Provider Demographics
NPI:1568145944
Name:SANDS, CLANCY (LMT)
Entity Type:Individual
Prefix:
First Name:CLANCY
Middle Name:
Last Name:SANDS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 CHERYL LN APT 5
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:OR
Mailing Address - Zip Code:97535-8701
Mailing Address - Country:US
Mailing Address - Phone:541-778-5929
Mailing Address - Fax:
Practice Address - Street 1:18 MYRTLE ST # 7025
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7338
Practice Address - Country:US
Practice Address - Phone:541-531-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27851225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR27851OtherOREGON BOARD OF MASSAGE