Provider Demographics
NPI:1255888616
Name:GWEN MANLOVE ESTHETICIAN & MASSAGE THERAPIST
Entity type:Organization
Organization Name:GWEN MANLOVE ESTHETICIAN & MASSAGE THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANLOVE
Authorized Official - Suffix:
Authorized Official - Credentials:18880
Authorized Official - Phone:503-679-9144
Mailing Address - Street 1:2025 SE JEFFERSON ST # 103
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7605
Mailing Address - Country:US
Mailing Address - Phone:503-679-9144
Mailing Address - Fax:
Practice Address - Street 1:2025 SE JEFFERSON ST # 103
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7605
Practice Address - Country:US
Practice Address - Phone:503-679-9144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18880225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty