Healthcare Provider Details

I. General information

NPI: 1699931147
Provider Name (Legal Business Name): MARIE A MITCHUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WILLIAM R MITCHUM

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 08/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 COMMERCIAL ST
ASTORIA OR
97103-4126
US

IV. Provider business mailing address

1130 COMMERCIAL ST
ASTORIA OR
97103-4126
US

V. Phone/Fax

Practice location:
  • Phone: 503-325-1030
  • Fax:
Mailing address:
  • Phone: 503-325-1030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberNOT REQUIRED
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: