Provider Demographics
NPI:1639422959
Name:EQUILIBRIA MASSAGE
Entity Type:Organization
Organization Name:EQUILIBRIA MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KAMILA
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOUPAL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-221-2155
Mailing Address - Street 1:1308 NW 20TH AVE SUITE 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:503-221-2155
Mailing Address - Fax:
Practice Address - Street 1:1308 NW 20TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1607
Practice Address - Country:US
Practice Address - Phone:503-221-2155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16166225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty