Provider Demographics
NPI:1679754709
Name:CLACKAMAS CENTER FOR TRADITIONAL MEDICINE, INC
Entity Type:Organization
Organization Name:CLACKAMAS CENTER FOR TRADITIONAL MEDICINE, INC
Other - Org Name:LAKE ROAD ACUPUNCTURE & MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:GRIESMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, RN
Authorized Official - Phone:503-653-1468
Mailing Address - Street 1:7831 SE LAKE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2193
Mailing Address - Country:US
Mailing Address - Phone:503-653-1468
Mailing Address - Fax:503-496-0727
Practice Address - Street 1:7831 SE LAKE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97267-2193
Practice Address - Country:US
Practice Address - Phone:503-653-1468
Practice Address - Fax:503-496-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00831171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty