Provider Demographics
NPI:1336281310
Name:ZIMMERMAN, RICHARD CLARK (LAC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CLARK
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-0960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 MAIN STREET
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540
Practice Address - Country:US
Practice Address - Phone:541-535-5082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00921171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213176Medicaid
OR213171Medicaid