Provider Demographics
NPI:1720481518
Name:RESTORE MASSAGE THERAPY, INC
Entity Type:Organization
Organization Name:RESTORE MASSAGE THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:APODACA
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-701-7714
Mailing Address - Street 1:1922 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1638
Mailing Address - Country:US
Mailing Address - Phone:503-701-7714
Mailing Address - Fax:
Practice Address - Street 1:1922 21ST AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1638
Practice Address - Country:US
Practice Address - Phone:503-701-7714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11539225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR225700000XOtherMASSAGE THERAPIST