Provider Demographics
NPI:1386929883
Name:BLOODSAW, CHAKA J I (LMT #16671)
Entity type:Individual
Prefix:MR
First Name:CHAKA
Middle Name:J
Last Name:BLOODSAW
Suffix:I
Gender:M
Credentials:LMT #16671
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:NEHALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97131-0351
Mailing Address - Country:US
Mailing Address - Phone:503-368-7964
Mailing Address - Fax:503-368-7964
Practice Address - Street 1:36450 N. FORK RD.
Practice Address - Street 2:
Practice Address - City:NEHALEM
Practice Address - State:OR
Practice Address - Zip Code:97131
Practice Address - Country:US
Practice Address - Phone:503-368-7964
Practice Address - Fax:503-368-7964
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16671172M00000X
WA60134001172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist