Healthcare Provider Details

I. General information

NPI: 1225263973
Provider Name (Legal Business Name): SAMUEL ADAM BISHOP LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 NW CIRCLE BLVD
CORVALLIS OR
97330-1410
US

IV. Provider business mailing address

2997 KALMIA CT
SWEET HOME OR
97386-2946
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-0325
  • Fax:
Mailing address:
  • Phone: 541-401-7028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16209
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: