Provider Demographics
NPI:1841420692
Name:MARYA DEDA INC
Entity Type:Organization
Organization Name:MARYA DEDA INC
Other - Org Name:ACUPUNCTURE ON BROADWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LAC, LMT
Authorized Official - Prefix:
Authorized Official - First Name:MARYA
Authorized Official - Middle Name:E DEDA
Authorized Official - Last Name:BARAKAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-282-2268
Mailing Address - Street 1:2933 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1760
Mailing Address - Country:US
Mailing Address - Phone:503-282-2268
Mailing Address - Fax:503-282-2863
Practice Address - Street 1:2933 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1760
Practice Address - Country:US
Practice Address - Phone:503-282-2268
Practice Address - Fax:503-282-2863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00978171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty