Organization
BODYWORK FOR THE ACTIVE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICARD M DEAUSTRIA JR. LMT (OWNER/LMT)
(971) 246-0057
Entity
Organization
Contact information
Practice address
2701 NW VAUGHN ST STE 154, PORTLAND, OR 97210-5349
(971) 246-0057
Mailing address
2701 NW VAUGHN ST STE 154, PORTLAND, OR 97210-5349
(971) 246-0057
Taxonomy
Speciality
Code
Description
License number
State
172M00000X
Mechanotherapist
Primary
15490
OR
Other
Enumeration date
04/02/2014
Last updated
04/02/2014
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