Provider Demographics
NPI:1740635713
Name:RESTORE MASSAGE PDX LLC
Entity type:Organization
Organization Name:RESTORE MASSAGE PDX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:REAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-570-1495
Mailing Address - Street 1:14833 SW 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7911
Mailing Address - Country:US
Mailing Address - Phone:971-570-1495
Mailing Address - Fax:
Practice Address - Street 1:14833 SW 72ND AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7911
Practice Address - Country:US
Practice Address - Phone:971-570-1495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17822305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service