Individual
AUSA PEACOCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
833 SE MAIN ST # 423, PORTLAND, OR 97214-3454
(503) 583-2872
Mailing address
6326 NE 25TH AVE, PORTLAND, OR 97211-6044
(503) 583-2872
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
15125
OR
Other
Enumeration date
10/19/2012
Last updated
10/19/2012
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