Provider Demographics
NPI:1972660603
Name:MIRBAHA, MARJON (LAC)
Entity Type:Individual
Prefix:
First Name:MARJON
Middle Name:
Last Name:MIRBAHA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NE NEFF RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6213
Mailing Address - Country:US
Mailing Address - Phone:541-388-0675
Mailing Address - Fax:541-388-0685
Practice Address - Street 1:2100 NE NEFF RD
Practice Address - Street 2:SUITE A
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6213
Practice Address - Country:US
Practice Address - Phone:541-388-0675
Practice Address - Fax:541-388-0685
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00855171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist