Provider Demographics
NPI:1710237896
Name:MARTIN BROTHER, L.AC.
Entity Type:Organization
Organization Name:MARTIN BROTHER, L.AC.
Other - Org Name:TRADITIONAL ACUPUNCTURE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BROTHER
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-723-0394
Mailing Address - Street 1:1785 WILLAMETTE FALLS DRIVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068
Mailing Address - Country:US
Mailing Address - Phone:503-723-0394
Mailing Address - Fax:503-650-9070
Practice Address - Street 1:1785 WILLAMETTE FALLS DR
Practice Address - Street 2:SUITE 7
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4568
Practice Address - Country:US
Practice Address - Phone:503-723-0394
Practice Address - Fax:503-650-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00820171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty