Provider Demographics
NPI:1275768434
Name:STARSIDE HEALING ARTS
Entity Type:Organization
Organization Name:STARSIDE HEALING ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RACHEL
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, LMT
Authorized Official - Phone:503-956-0912
Mailing Address - Street 1:1308 NW 20TH AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1607
Mailing Address - Country:US
Mailing Address - Phone:503-956-0912
Mailing Address - Fax:503-715-4923
Practice Address - Street 1:1308 NW 20TH AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1607
Practice Address - Country:US
Practice Address - Phone:503-956-0912
Practice Address - Fax:503-715-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01160171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty