Provider Demographics
NPI:1225250350
Name:BARE, GEORGE LOUIS
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:LOUIS
Last Name:BARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12425 NW BARNES RD APT 99
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6095
Mailing Address - Country:US
Mailing Address - Phone:971-404-6555
Mailing Address - Fax:
Practice Address - Street 1:4610 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2910
Practice Address - Country:US
Practice Address - Phone:971-404-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10701OtherMASSAGE LICENSE