Provider Demographics
NPI:1578790226
Name:MCMAHON, MICHAEL C (LAC, LMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:MCMAHON
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 SE HAWTHORNE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3160
Mailing Address - Country:US
Mailing Address - Phone:503-351-8853
Mailing Address - Fax:
Practice Address - Street 1:4203 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3160
Practice Address - Country:US
Practice Address - Phone:503-351-8853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROREGON LMT 14129174400000X
OROR 156717171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist