Provider Demographics
NPI:1457720450
Name:BOURNE, MARK ALAN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:BOURNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 HIGHWAY 101 # 168
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-7634
Mailing Address - Country:US
Mailing Address - Phone:503-789-4374
Mailing Address - Fax:
Practice Address - Street 1:625 HIGHWAY 101 # 168
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-7634
Practice Address - Country:US
Practice Address - Phone:503-789-4374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-20
Last Update Date:2015-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications