1356013452 NPI number — BEND LIFE ACUPUNCTURE & INTEGRATIVE MEDICINE LLC

Table of content: MARK L. HENDERSON LCSW (NPI 1083606826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356013452 NPI number — BEND LIFE ACUPUNCTURE & INTEGRATIVE MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEND LIFE ACUPUNCTURE & INTEGRATIVE MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356013452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97293-0100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-384-2988
Provider Business Mailing Address Fax Number:
971-302-7048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1291 NW WALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97703-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-728-3481
Provider Business Practice Location Address Fax Number:
971-302-7048
Provider Enumeration Date:
09/28/2021

Additional Information

Authorized Official

Authorized Official Last Name:
CARMICHAEL
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-728-3481

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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