Healthcare Provider Details

I. General information

NPI: 1376856864
Provider Name (Legal Business Name): CORVALLIS NATURAL MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 NW CIRCLE BLVD
CORVALLIS OR
97330-1408
US

IV. Provider business mailing address

999 NW CIRCLE BLVD
CORVALLIS OR
97330-1408
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-2225
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01019
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1514
License Number StateOR

VIII. Authorized Official

Name: DR. DEBORAH NIXDORF
Title or Position: OWNER/PRESIDENT
Credential: ND, LAC
Phone: 541-754-2225