Provider Demographics
NPI:1083797922
Name:GREENLY, MARI PATRICE (LAC)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:PATRICE
Last Name:GREENLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 E BURNSIDE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1655
Mailing Address - Country:US
Mailing Address - Phone:503-349-8122
Mailing Address - Fax:971-319-2195
Practice Address - Street 1:2311 E BURNSIDE ST STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1655
Practice Address - Country:US
Practice Address - Phone:503-349-8122
Practice Address - Fax:971-319-2195
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00938171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR900947265OtherTAX ID #