Organization
BREATHE BODY SPA, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KELLY RYAN VAN DYKE LMT (OWNER/LMT)
(971) 267-5227
Entity
Organization
Contact information
Practice address
205 NE FORD ST, MCMINNVILLE, OR 97128-4632
(971) 267-5227
Mailing address
940 SE LOCUST ST, DUNDEE, OR 97115-9630
(503) 915-6021
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
22338
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22338
LICENSED MASSAGE THERAPIST
OR
Enumeration date
09/16/2016
Last updated
09/16/2016
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