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General NPI Number Information
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NPI Number | 1306717939
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Entity Type | Individual
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Provider Name | CHARLES NICHOLAS PORTLOCK LMT
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Gender |
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Dates
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Enumeration Date | 09/16/2025
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Last Update Date | 09/16/2025
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Provider Practice Location Address
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Address Line | 2627 NE MARTIN LUTHER KING JR BLVD
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City | PORTLAND
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State | OR
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Zip | 97212-3758
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Country | US
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Telephone | 503-493-9398
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Fax |
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Provider Business Mailing Address
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Address Line | 301 SW LINCOLN ST APT 606
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City | PORTLAND
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State | OR
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Zip | 97201-5029
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Country | US
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Telephone | 206-399-5936
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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 | LMT26373
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License Number State | OR
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