Provider Demographics
NPI:1437718764
Name:IRVINE, RICHARD C JR (LMT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:C
Last Name:IRVINE
Suffix:JR
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 1:12843 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1555
Mailing Address - Country:US
Mailing Address - Phone:503-473-5022
Mailing Address - Fax:
Practice Address - Street 1:3 MONROE PKWY STE 100U
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-1486
Practice Address - Country:US
Practice Address - Phone:503-387-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24893225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist