Provider Demographics
NPI:1225263973
Name:BISHOP, SAMUEL ADAM (LMT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ADAM
Last Name:BISHOP
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2997 KALMIA CT
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-2946
Mailing Address - Country:US
Mailing Address - Phone:541-401-7028
Mailing Address - Fax:
Practice Address - Street 1:970 NW CIRCLE BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1410
Practice Address - Country:US
Practice Address - Phone:541-754-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16209225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist