Provider Demographics
NPI:1558494062
Name:KAUFMAN, LARRY (LMT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:KAUFMAN
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 1:1423 SE 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3908
Mailing Address - Country:US
Mailing Address - Phone:503-236-3108
Mailing Address - Fax:503-236-3239
Practice Address - Street 1:1423 SE 23RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3908
Practice Address - Country:US
Practice Address - Phone:503-236-3108
Practice Address - Fax:503-236-3239
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12482225700000X
WAMA00009527225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist