Provider Demographics
NPI:1669687729
Name:GRANDE RONDE THERAPEUTIC MASSAGE
Entity Type:Organization
Organization Name:GRANDE RONDE THERAPEUTIC MASSAGE
Other - Org Name:PEGGY LITTLE LMT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER LICENSED MASSAG THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-963-4764
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OR
Mailing Address - Zip Code:97827
Mailing Address - Country:US
Mailing Address - Phone:541-437-0865
Mailing Address - Fax:
Practice Address - Street 1:1609 ALBANY ST
Practice Address - Street 2:#10
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-963-4764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3427225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty