Provider Demographics
NPI:1053857482
Name:IAN WILKINSON LAC
Entity Type:Organization
Organization Name:IAN WILKINSON LAC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:541-706-1888
Mailing Address - Street 1:342 NE MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-2934
Mailing Address - Country:US
Mailing Address - Phone:541-706-1888
Mailing Address - Fax:
Practice Address - Street 1:4829 NE MARTIN LUTHER KING BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3491
Practice Address - Country:US
Practice Address - Phone:541-706-1888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC179984305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization