Provider Demographics
NPI:1598970550
Name:SUMNER, MICHAEL BENJAMIN SR (LMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BENJAMIN
Last Name:SUMNER
Suffix:SR
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 1:390 SALEM HEIGHTS AVE S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5609
Mailing Address - Country:US
Mailing Address - Phone:503-371-1901
Mailing Address - Fax:
Practice Address - Street 1:390 SALEM HEIGHTS AVE S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5609
Practice Address - Country:US
Practice Address - Phone:503-371-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10763172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10763OtherLMT LISENCE