Provider Demographics
NPI:1417207994
Name:SPORTLAND ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:SPORTLAND ACUPUNCTURE LLC
Other - Org Name:SPORTLAND ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE MOORE
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-679-3872
Mailing Address - Street 1:1025 N HUMBOLDT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217
Mailing Address - Country:US
Mailing Address - Phone:503-679-3872
Mailing Address - Fax:
Practice Address - Street 1:1025 N HUMBOLDT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217
Practice Address - Country:US
Practice Address - Phone:503-679-3872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC156421171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty