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General NPI Number Information
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NPI Number | 1174763692
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Entity Type | Individual
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Provider Name | BENJAMIN CARLOS MARTIN LMT
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Gender | Male
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Dates
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Enumeration Date | 02/24/2009
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Last Update Date | 02/24/2009
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Provider Practice Location Address
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Address Line | 5010 NE 33RD AVE
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City | PORTLAND
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State | OR
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Zip | 97211-6946
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Country | US
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Telephone | 503-238-1065
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Fax |
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Provider Business Mailing Address
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Address Line | 2926 NE FLANDERS ST
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City | PORTLAND
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State | OR
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Zip | 97232-3259
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Country | US
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Telephone | 503-239-7452
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 1073
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License Number State | OR
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