Provider Demographics
NPI:1689059552
Name:KANDLE, BRUCE JARROD (LMT, MP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:JARROD
Last Name:KANDLE
Suffix:
Gender:M
Credentials:LMT, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77895 LUPINE LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:OR
Mailing Address - Zip Code:97886-6006
Mailing Address - Country:US
Mailing Address - Phone:541-566-2725
Mailing Address - Fax:
Practice Address - Street 1:77895 LUPINE LN
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:OR
Practice Address - Zip Code:97886-6006
Practice Address - Country:US
Practice Address - Phone:541-566-2725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60563683225700000X
OR21472225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60563683OtherMASSAGE THERAPIST
OR21472OtherMASSAGE THERAPIST