Provider Demographics
NPI:1720773328
Name:EPICENTER THERAPEUTIC BODYWORK AND MASSAGE LLC
Entity type:Organization
Organization Name:EPICENTER THERAPEUTIC BODYWORK AND MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FENICKS
Authorized Official - Middle Name:
Authorized Official - Last Name:RENASCI
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-525-8115
Mailing Address - Street 1:4475 SW SCHOLLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1955
Mailing Address - Country:US
Mailing Address - Phone:541-525-8115
Mailing Address - Fax:
Practice Address - Street 1:4475 SW SCHOLLS FERRY RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1955
Practice Address - Country:US
Practice Address - Phone:541-525-8115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty