Provider Demographics
NPI:1659886406
Name:COLOVOS, SHYLA
Entity Type:Individual
Prefix:
First Name:SHYLA
Middle Name:
Last Name:COLOVOS
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 1:1255 NE TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1348
Mailing Address - Country:US
Mailing Address - Phone:541-633-0375
Mailing Address - Fax:
Practice Address - Street 1:320 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1861
Practice Address - Country:US
Practice Address - Phone:541-633-0375
Practice Address - Fax:541-633-0375
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12770225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist