Provider Demographics
NPI:1336391861
Name:MICAH FAY BODY TREATMENTS INC
Entity Type:Organization
Organization Name:MICAH FAY BODY TREATMENTS INC
Other - Org Name:MICAH FAY
Other - Org Type:Other Name
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:MICAH
Authorized Official - Last Name:HILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-955-4695
Mailing Address - Street 1:1156 NE D ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2322
Mailing Address - Country:US
Mailing Address - Phone:541-955-4695
Mailing Address - Fax:
Practice Address - Street 1:1156 NE D ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2322
Practice Address - Country:US
Practice Address - Phone:541-955-4695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7648225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty