Healthcare Provider Details

I. General information

NPI: 1326605932
Provider Name (Legal Business Name): KORINNE MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NE DIVISION ST
GRESHAM OR
97030-3947
US

IV. Provider business mailing address

923 NE 55TH AVE
PORTLAND OR
97213-3604
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-0791
  • Fax:
Mailing address:
  • Phone: 414-484-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number25020
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: