Provider Demographics
NPI:1487984878
Name:LYONS, TINA LOUISE (LMT, LMP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:LYONS
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3643
Mailing Address - Street 2:
Mailing Address - City:SUNRIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97707-0643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56825 VENTURE LN
Practice Address - Street 2:SUITE 108
Practice Address - City:SUNRIVER
Practice Address - State:OR
Practice Address - Zip Code:97707-2160
Practice Address - Country:US
Practice Address - Phone:541-598-4083
Practice Address - Fax:541-593-7465
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4857172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist