Provider Demographics
NPI:1982658621
Name:VINCENT, MYCHELL E (LAC)
Entity Type:Individual
Prefix:
First Name:MYCHELL
Middle Name:E
Last Name:VINCENT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9205 SE CLACKAMAS RD
Mailing Address - Street 2:# 147
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9657
Mailing Address - Country:US
Mailing Address - Phone:503-656-5510
Mailing Address - Fax:503-656-8080
Practice Address - Street 1:15480 SE 82ND DR
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9633
Practice Address - Country:US
Practice Address - Phone:503-656-5510
Practice Address - Fax:503-656-8080
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00408171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist