Provider Demographics
NPI:1275947723
Name:LITTLE WING ACUPUNCTURE
Entity Type:Organization
Organization Name:LITTLE WING ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENOM
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MACOM
Authorized Official - Phone:503-224-2525
Mailing Address - Street 1:833 SW 11TH AVE
Mailing Address - Street 2:SUITE #1018
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2125
Mailing Address - Country:US
Mailing Address - Phone:503-224-2525
Mailing Address - Fax:503-224-3397
Practice Address - Street 1:833 SW 11TH AVE
Practice Address - Street 2:SUITE #1018
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2125
Practice Address - Country:US
Practice Address - Phone:503-224-2525
Practice Address - Fax:503-224-3397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC156429171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty