Healthcare Provider Details

I. General information

NPI: 1396667788
Provider Name (Legal Business Name): MAXON RYAN GRIFFIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 SW SIMPSON AVE STE 140
BEND OR
97702-3599
US

IV. Provider business mailing address

717 NW GEORGIA AVE UNIT 3
BEND OR
97703-3261
US

V. Phone/Fax

Practice location:
  • Phone: 541-617-9771
  • Fax:
Mailing address:
  • Phone: 541-948-7208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number29788
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: