Provider Demographics
NPI:1740757632
Name:LARSEN, ELIZABETH (MACOM, LAC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 SW MOSS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2742
Mailing Address - Country:US
Mailing Address - Phone:831-419-9590
Mailing Address - Fax:
Practice Address - Street 1:1308 NW 20TH AVE STE 10
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1607
Practice Address - Country:US
Practice Address - Phone:503-218-3737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC190005171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist