Provider Demographics
NPI:1538694229
Name:AMANDA REAL, LAC.
Entity Type:Organization
Organization Name:AMANDA REAL, LAC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:REAL
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-560-0963
Mailing Address - Street 1:8707 SE 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7005
Mailing Address - Country:US
Mailing Address - Phone:503-560-0963
Mailing Address - Fax:
Practice Address - Street 1:8707 SE 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7005
Practice Address - Country:US
Practice Address - Phone:503-560-0963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01226171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty