Provider Demographics
NPI:1417120775
Name:PACIFIC NORTHWEST ACUPUNCTURE&HERBAL CLINIC,LLC
Entity Type:Organization
Organization Name:PACIFIC NORTHWEST ACUPUNCTURE&HERBAL CLINIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOVA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-684-9717
Mailing Address - Street 1:6655 SW HAMPTON ST
Mailing Address - Street 2:SUITE100
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8300
Mailing Address - Country:US
Mailing Address - Phone:503-684-9717
Mailing Address - Fax:503-684-6038
Practice Address - Street 1:6655 SW HAMPTON ST
Practice Address - Street 2:SUITE100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8300
Practice Address - Country:US
Practice Address - Phone:503-684-9717
Practice Address - Fax:503-684-6038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00597171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty