Provider Demographics
NPI:1982924841
Name:NYSTROM THERAPUTIC MASSAGE
Entity Type:Organization
Organization Name:NYSTROM THERAPUTIC MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:YARLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NYSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-756-9076
Mailing Address - Street 1:9900 SW WILSHIRE ST STE 190-E
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5035
Mailing Address - Country:US
Mailing Address - Phone:503-756-9076
Mailing Address - Fax:503-297-3827
Practice Address - Street 1:9900 SW WILSHIRE ST STE 190-E
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5035
Practice Address - Country:US
Practice Address - Phone:503-756-9076
Practice Address - Fax:503-297-3827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11353225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty