Provider Demographics
NPI:1497821565
Name:CAPITANO, ALICE LEEYONGE (DC)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:LEEYONGE
Last Name:CAPITANO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 NE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3150
Mailing Address - Country:US
Mailing Address - Phone:503-230-0812
Mailing Address - Fax:503-233-9151
Practice Address - Street 1:316 NE 28TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3150
Practice Address - Country:US
Practice Address - Phone:503-230-0812
Practice Address - Fax:503-233-9151
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-3251111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR140931OtherMEDICARE GROUP PIN
OR140930Medicare PIN
OR140931OtherMEDICARE GROUP PIN