Healthcare Provider Details

I. General information

NPI: 1659192037
Provider Name (Legal Business Name): MOUNTAIN AIR FUNCTIONAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MAIN ST
BAKER CITY OR
97814-2655
US

IV. Provider business mailing address

2100 MAIN ST
BAKER CITY OR
97814-2655
US

V. Phone/Fax

Practice location:
  • Phone: 541-519-0694
  • Fax:
Mailing address:
  • Phone: 541-519-0694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. RICHARD CHARLES HERIZA
Title or Position: OWNER
Credential: ND, MPH
Phone: 541-519-0694