Provider Demographics
NPI:1407103914
Name:GARCIA, ADALISSETE (LAC)
Entity Type:Individual
Prefix:
First Name:ADALISSETE
Middle Name:
Last Name:GARCIA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6442 SW 46TH PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2806
Mailing Address - Country:US
Mailing Address - Phone:971-322-8136
Mailing Address - Fax:
Practice Address - Street 1:10001 SE SUNNYSIDE RD
Practice Address - Street 2:#204
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5746
Practice Address - Country:US
Practice Address - Phone:503-908-0881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC155013171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist