Provider Demographics
NPI:1477720365
Name:COBLENTZ, MARTIE M (LMT)
Entity Type:Individual
Prefix:MS
First Name:MARTIE
Middle Name:M
Last Name:COBLENTZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:M
Other - Last Name:COBLENTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:27725 JAHN RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RONDE
Mailing Address - State:OR
Mailing Address - Zip Code:97347-9735
Mailing Address - Country:US
Mailing Address - Phone:503-510-9110
Mailing Address - Fax:503-879-5931
Practice Address - Street 1:27725 JAHN RD
Practice Address - Street 2:
Practice Address - City:GRAND RONDE
Practice Address - State:OR
Practice Address - Zip Code:97347-9735
Practice Address - Country:US
Practice Address - Phone:503-510-9110
Practice Address - Fax:503-879-5931
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-11
Last Update Date:2008-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 12030171W00000X
WAMAQ00021059171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor