Healthcare Provider Details

I. General information

NPI: 1386988236
Provider Name (Legal Business Name): GREGORY GRIFFIN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 NW FAIRVIEW DR
GRESHAM OR
97030-3842
US

IV. Provider business mailing address

5030 SE 85TH AVE
PORTLAND OR
97266-3120
US

V. Phone/Fax

Practice location:
  • Phone: 503-492-3910
  • Fax: 503-674-6706
Mailing address:
  • Phone: 505-575-5459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16352
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: