Provider Demographics
NPI:1588112676
Name:BREATHE BODY SPA, LLC
Entity type:Organization
Organization Name:BREATHE BODY SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LMT
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:VAN DYKE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:971-267-5227
Mailing Address - Street 1:940 SE LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-9630
Mailing Address - Country:US
Mailing Address - Phone:503-915-6021
Mailing Address - Fax:
Practice Address - Street 1:205 NE FORD ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4632
Practice Address - Country:US
Practice Address - Phone:971-267-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22338225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22338OtherLICENSED MASSAGE THERAPIST