Provider Demographics
NPI:1134216450
Name:BRAIDE, JOHN ARON (LAC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ARON
Last Name:BRAIDE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:ERNEST
Other - Last Name:SERVILIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5412 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2740
Mailing Address - Country:US
Mailing Address - Phone:971-373-8378
Mailing Address - Fax:971-373-8912
Practice Address - Street 1:5412 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2740
Practice Address - Country:US
Practice Address - Phone:971-373-8378
Practice Address - Fax:971-373-8378
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC152456171100000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA611473200OtherDOL FECA