Provider Demographics
NPI:1154661163
Name:SUNDARA ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:SUNDARA ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNTURIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PHAVIXAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDARA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-382-7179
Mailing Address - Street 1:17175 SW LISA ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4185
Mailing Address - Country:US
Mailing Address - Phone:503-382-7179
Mailing Address - Fax:
Practice Address - Street 1:17175 SW LISA ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4185
Practice Address - Country:US
Practice Address - Phone:503-382-7179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC151174261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty