Provider Demographics
NPI:1952823023
Name:PACKMAN, DAN
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:PACKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61516 DIAMOND LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 N. HWY 97, STE 105
Practice Address - Street 2:RIVERSIDE WELLNESS, VOILA MASSAGE
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703
Practice Address - Country:US
Practice Address - Phone:541-647-9483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21532225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist