Provider Demographics
NPI:1518366848
Name:WATANABE, MIKA LINETTE (LAC)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:LINETTE
Last Name:WATANABE
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 1:612 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1404
Mailing Address - Country:US
Mailing Address - Phone:503-873-6705
Mailing Address - Fax:
Practice Address - Street 1:612 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1404
Practice Address - Country:US
Practice Address - Phone:503-873-6705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC169428171100000X
VT091.0099715171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist