Provider Demographics
NPI:1770040057
Name:TEAR OF THE BUDDHA LLC
Entity Type:Organization
Organization Name:TEAR OF THE BUDDHA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:GOLLIHER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:307-699-7320
Mailing Address - Street 1:9100 N BUCHANAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-2433
Mailing Address - Country:US
Mailing Address - Phone:307-699-7320
Mailing Address - Fax:
Practice Address - Street 1:322 NW 5TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3825
Practice Address - Country:US
Practice Address - Phone:503-227-0206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty