| Organization Name: | LAKE GROVE WELLNESS |
| NPI Number: | 1053723536 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | KATHLEEEN JORDAN (OWNER) |
| Mailing Address: | 16320 Bryant Rd Lake Oswego |
| State: | OR US |
| Postal Code: | 970354308 |
| Phone Number: | 5039081180 |
| Fax Number: | |
| NPI Enumeration Date: | 06/02/2014 |
| NPI Last Update Date: | 06/02/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225700000X |
| License Number: | 6748 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Massage Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual trained in the manipulation of tissues (as by rubbing, stroking, kneading, or tapping) with the hand or an instrument for remedial or hygienic purposes. |