Provider Demographics
NPI:1598023046
Name:LUNDBERG, LESLIE ELAINE (LAC, DOM)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ELAINE
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:LAC, DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:GOLD HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97525-0772
Mailing Address - Country:US
Mailing Address - Phone:541-855-5508
Mailing Address - Fax:
Practice Address - Street 1:325 2ND AVE
Practice Address - Street 2:
Practice Address - City:GOLD HILL
Practice Address - State:OR
Practice Address - Zip Code:97525-0772
Practice Address - Country:US
Practice Address - Phone:541-855-5508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC154828171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist