Healthcare Provider Details

I. General information

NPI: 1497017396
Provider Name (Legal Business Name): GLENNA MACKINNON LMT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 OAK ST
EUGENE OR
97401-4022
US

IV. Provider business mailing address

115 ELKAY DR
EUGENE OR
97404-3060
US

V. Phone/Fax

Practice location:
  • Phone: 541-525-6141
  • Fax:
Mailing address:
  • Phone: 541-525-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number5231
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: GLENNA MACKINNON
Title or Position: LICENSED MASSAGE THERAPIST
Credential: LMT
Phone: 541-525-6141