1235239203 NPI number — ACORN HEALING ARTS, LLC

Table of content: (NPI 1235239203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235239203 NPI number — ACORN HEALING ARTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACORN HEALING ARTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235239203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
704 SE UMATILLA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97202-6439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-234-2285
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1616 SW SUNSET BLVD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-2641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-245-1459
Provider Business Practice Location Address Fax Number:
503-293-2023
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONTAGNE
Authorized Official First Name:
MORI
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
503-245-1459

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  092000262N5 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QH0100X , with the licence number: 092000262N5 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0836369 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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