Provider Demographics
NPI:1629535653
Name:EXPEDITION ACUPUNCTURE
Entity Type:Organization
Organization Name:EXPEDITION ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, LMT
Authorized Official - Phone:503-748-9399
Mailing Address - Street 1:80 SE MADISON ST STE 216
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4527
Mailing Address - Country:US
Mailing Address - Phone:503-748-9399
Mailing Address - Fax:
Practice Address - Street 1:80 SE MADISON ST STE 216
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4527
Practice Address - Country:US
Practice Address - Phone:503-748-9399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty