Provider Demographics
NPI:1477852457
Name:THIMMESCH, MARY J (LAC, MSOM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:THIMMESCH
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-4236
Mailing Address - Country:US
Mailing Address - Phone:541-684-5993
Mailing Address - Fax:
Practice Address - Street 1:395 W BROADWAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2869
Practice Address - Country:US
Practice Address - Phone:541-683-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01080171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR27-0510674OtherEIN