Provider Demographics
NPI:1033315957
Name:BEVERLY M. MADISON L.AC. P.C.
Entity Type:Organization
Organization Name:BEVERLY M. MADISON L.AC. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURISTS
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-288-7661
Mailing Address - Street 1:2524 NE 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2923
Mailing Address - Country:US
Mailing Address - Phone:503-288-7661
Mailing Address - Fax:
Practice Address - Street 1:2524 NE 39TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2923
Practice Address - Country:US
Practice Address - Phone:503-288-7661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR100171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty