Provider Demographics
NPI:1043646599
Name:SUSAN SACCOMANNO ND LAC INC
Entity Type:Organization
Organization Name:SUSAN SACCOMANNO ND LAC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATUROPATH
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SACCOMANNO
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:503-799-4663
Mailing Address - Street 1:3909 SE 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3231
Mailing Address - Country:US
Mailing Address - Phone:503-224-2525
Mailing Address - Fax:
Practice Address - Street 1:833 SW 11TH AVE
Practice Address - Street 2:SUITE #1018
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2125
Practice Address - Country:US
Practice Address - Phone:503-224-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUSAN SACCOMANNO ND LAC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01026171100000X
OR1527175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty