Provider Demographics
NPI:1720424062
Name:LIFESTYLE NUTRITION AND MASSAGE
Entity Type:Organization
Organization Name:LIFESTYLE NUTRITION AND MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:DOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:971-221-5685
Mailing Address - Street 1:418 BEAVERCREEK RD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4287
Mailing Address - Country:US
Mailing Address - Phone:503-723-4462
Mailing Address - Fax:
Practice Address - Street 1:418 BEAVERCREEK RD
Practice Address - Street 2:SUITE #102
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-723-4462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13402302R00000X
OR13385302R00000X
OR13848302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization