Healthcare Provider Details

I. General information

NPI: 1063649952
Provider Name (Legal Business Name): ANNIE O BOWLBY LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 COMMERCE AVE STE 101
LONGVIEW WA
98632-3090
US

IV. Provider business mailing address

138 ALPHA DR
LONGVIEW WA
98632-5804
US

V. Phone/Fax

Practice location:
  • Phone: 360-270-4214
  • Fax:
Mailing address:
  • Phone: 360-501-6474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA00007320
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: