Healthcare Provider Details

I. General information

NPI: 1760052443
Provider Name (Legal Business Name): NATHAN L HOLLENBECK R EEG T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 LIBERTY RD S
SALEM OR
97302-4560
US

IV. Provider business mailing address

903 GARLOCK ST S
SALEM OR
97302-6022
US

V. Phone/Fax

Practice location:
  • Phone: 503-269-2621
  • Fax:
Mailing address:
  • Phone: 503-269-2621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number5811
License Number State
# 5
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number5811
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: