Provider Demographics
NPI:1912722596
Name:EXPANSE MASSAGE & BODYWORK LLC
Entity type:Organization
Organization Name:EXPANSE MASSAGE & BODYWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:928-853-9929
Mailing Address - Street 1:5918 NE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6128
Mailing Address - Country:US
Mailing Address - Phone:928-853-9929
Mailing Address - Fax:
Practice Address - Street 1:3939 NE HANCOCK ST STE 311
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-5321
Practice Address - Country:US
Practice Address - Phone:928-853-9929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty