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NPI Code Detail

MEDICARE: MR. ALEXANDER CHARLES BRODER

MEDICARE: MR. ALEXANDER CHARLES BRODER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225700000XMassage Therapist17536OR

General Provider Information

NPI Number : 1669199469
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ALEXANDER CHARLES BRODER
Provider Business Mailing Address
First Line : 2149 NE BROADWAY ST
Second Line :
City : PORTLAND
State : OR
Zip : 97232-1580
Country : US
Telephone Number : 503-281-0278
Fax Number :
Provider Business Practice Location Address
First Line : 2149 NE BROADWAY ST
Second Line :
City : PORTLAND
State : OR
Zip : 97232-1580
Country : US
Telephone Number : 503-281-0278
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/21/2022
Last Update Date : 10/21/2022

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