Provider Demographics
NPI:1720635733
Name:CORVALLIS ACUPUNCTURE AND FUNCTIONAL MEDICINE, LLC
Entity Type:Organization
Organization Name:CORVALLIS ACUPUNCTURE AND FUNCTIONAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:B
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:541-380-1327
Mailing Address - Street 1:475 NE CONIFER BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4195
Mailing Address - Country:US
Mailing Address - Phone:541-380-1327
Mailing Address - Fax:541-588-6208
Practice Address - Street 1:1760 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1725
Practice Address - Country:US
Practice Address - Phone:541-380-1327
Practice Address - Fax:541-588-6208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty