Basic Information
| Provider Information | |||||||||
| NPI: | 1710231154 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TATARYN | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1875 GOLF COURSE RD S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973029622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034006110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 GLEN CREEK RD NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973043058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039908627 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2012 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 19474 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.