Provider Demographics
NPI:1316293772
Name:TODD, MARK WAYNE (LAC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:TODD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2243
Mailing Address - Country:US
Mailing Address - Phone:503-481-9904
Mailing Address - Fax:
Practice Address - Street 1:322 NW 5TH AVE
Practice Address - Street 2:STE 305
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3825
Practice Address - Country:US
Practice Address - Phone:503-481-9904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC154188171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist