Provider Demographics
NPI:1215778261
Name:WELCH, MAX (MATRN, LAT, ATC)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:WELCH
Suffix:
Gender:M
Credentials:MATRN, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 SE YUKON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5317
Mailing Address - Country:US
Mailing Address - Phone:503-490-4775
Mailing Address - Fax:
Practice Address - Street 1:11020 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-6424
Practice Address - Country:US
Practice Address - Phone:503-830-7027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR102306062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer