Provider Demographics
NPI:1285913871
Name:BALGAMWALLA, ADAM (LMT)
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:BALGAMWALLA
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 1:10642 SE 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2098
Mailing Address - Country:US
Mailing Address - Phone:503-888-5457
Mailing Address - Fax:
Practice Address - Street 1:22000 WILLAMETTE DR
Practice Address - Street 2:SUITE NUMBER #107
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3275
Practice Address - Country:US
Practice Address - Phone:503-722-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16821225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist