Provider Demographics
NPI:1588090856
Name:CHAMP, MACKENZIE ANNE (ND, LAC)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ANNE
Last Name:CHAMP
Suffix:
Gender:F
Credentials:ND, LAC
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 504
Mailing Address - Street 2:
Mailing Address - City:NEHALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97131-0504
Mailing Address - Country:US
Mailing Address - Phone:503-368-4312
Mailing Address - Fax:503-368-4315
Practice Address - Street 1:35890 HIGHWAY 101 N
Practice Address - Street 2:
Practice Address - City:NEHALEM
Practice Address - State:OR
Practice Address - Zip Code:97131-9599
Practice Address - Country:US
Practice Address - Phone:503-368-4312
Practice Address - Fax:503-368-4315
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR156719171100000X
OR14010173C00000X
OR2005175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
No173C00000XOther Service ProvidersReflexologist