Healthcare Provider Details

I. General information

NPI: 1720635733
Provider Name (Legal Business Name): CORVALLIS ACUPUNCTURE AND FUNCTIONAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 SW 3RD ST
CORVALLIS OR
97333-1725
US

IV. Provider business mailing address

475 NE CONIFER BLVD
CORVALLIS OR
97330-4195
US

V. Phone/Fax

Practice location:
  • Phone: 541-380-1327
  • Fax: 541-588-6208
Mailing address:
  • Phone: 541-380-1327
  • Fax: 541-588-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: MR. ALEXANDER B DIAZ
Title or Position: LEAD PRACTITIONER
Credential: L.AC.
Phone: 541-380-1327