Healthcare Provider Details

I. General information

NPI: 1326357575
Provider Name (Legal Business Name): COLBY L HARTSELL LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 NW 4TH ST SUITE B
REDMOND OR
97756-1328
US

IV. Provider business mailing address

805 SW INDUSTRIAL WAY SUITE 3
BEND OR
97702-1093
US

V. Phone/Fax

Practice location:
  • Phone: 541-504-2350
  • Fax: 541-504-2354
Mailing address:
  • Phone: 541-585-2529
  • Fax: 541-585-2536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC153242
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: