1477720365 NPI number — MS. MARTIE M COBLENTZ LMT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477720365 NPI number — MS. MARTIE M COBLENTZ LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COBLENTZ
Provider First Name:
MARTIE
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COBLENTZ
Provider Other First Name:
MARTHA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1477720365
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27725 JAHN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RONDE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97347-9735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-510-9110
Provider Business Mailing Address Fax Number:
503-879-5931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27725 JAHN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RONDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97347-9735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-510-9110
Provider Business Practice Location Address Fax Number:
503-879-5931
Provider Enumeration Date:
05/11/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  OR 12030 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171W00000X , with the licence number: MAQ00021059 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)