=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720635733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORVALLIS ACUPUNCTURE AND FUNCTIONAL MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2019
-----------------------------------------------------
Last Update Date | 05/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1760 SW 3RD ST
-----------------------------------------------------
City | CORVALLIS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97333-1725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-380-1327
-----------------------------------------------------
Fax | 541-588-6208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 475 NE CONIFER BLVD
-----------------------------------------------------
City | CORVALLIS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97330-4195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-380-1327
-----------------------------------------------------
Fax | 541-588-6208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LEAD PRACTITIONER
-----------------------------------------------------
Name | MR. ALEXANDER B DIAZ
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 541-380-1327
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------