Provider Demographics
NPI:1114579109
Name:CRATER LAKE ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:CRATER LAKE ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF LLC
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM, LAC
Authorized Official - Phone:541-531-2151
Mailing Address - Street 1:524 ST AUGUSTINE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-2154
Mailing Address - Country:US
Mailing Address - Phone:541-531-2151
Mailing Address - Fax:541-262-4100
Practice Address - Street 1:1245 N RIVERSIDE AVE STE 14
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-4655
Practice Address - Country:US
Practice Address - Phone:541-249-9200
Practice Address - Fax:541-262-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty