Provider Demographics
NPI:1386027050
Name:HAWTHORNE ACUPUNCTURE, LLC
Entity Type:Organization
Organization Name:HAWTHORNE ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-236-9609
Mailing Address - Street 1:4531 SE BEMONT ST
Mailing Address - Street 2:STE 203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1675
Mailing Address - Country:US
Mailing Address - Phone:503-236-9609
Mailing Address - Fax:503-236-2906
Practice Address - Street 1:4531 SE BELMONT ST STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1675
Practice Address - Country:US
Practice Address - Phone:503-236-9609
Practice Address - Fax:503-236-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
ORAC164280171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500689108Medicaid