1417120775 NPI number — PACIFIC NORTHWEST ACUPUNCTURE&HERBAL CLINIC,LLC

Table of content: (NPI 1417120775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417120775 NPI number — PACIFIC NORTHWEST ACUPUNCTURE&HERBAL CLINIC,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC NORTHWEST ACUPUNCTURE&HERBAL CLINIC,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:
1417120775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6655 SW HAMPTON ST
Provider Second Line Business Mailing Address:
SUITE100
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-684-9717
Provider Business Mailing Address Fax Number:
503-684-6038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6655 SW HAMPTON ST
Provider Second Line Business Practice Location Address:
SUITE100
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223-8300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-684-9717
Provider Business Practice Location Address Fax Number:
503-684-6038
Provider Enumeration Date:
04/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DUBOVA
Authorized Official First Name:
MARIANNA
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSED ACUPUNCTURIST
Authorized Official Telephone Number:
503-684-9717

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC00597 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com