Healthcare Provider Details

I. General information

NPI: 1134519549
Provider Name (Legal Business Name): DAVID MARTIN OBANDO ANMT, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 SW 3RD ST SUITE 212
CORVALLIS OR
97333-4692
US

IV. Provider business mailing address

PO BOX 83476
PORTLAND OR
97283-0476
US

V. Phone/Fax

Practice location:
  • Phone: 541-286-5268
  • Fax:
Mailing address:
  • Phone: 541-286-5268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19202
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: