Provider Demographics
NPI:1700288669
Name:MACODRUM, MALEA (ND, MSOM)
Entity Type:Individual
Prefix:
First Name:MALEA
Middle Name:
Last Name:MACODRUM
Suffix:
Gender:F
Credentials:ND, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 SE 33RD PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3056
Mailing Address - Country:US
Mailing Address - Phone:503-754-5397
Mailing Address - Fax:
Practice Address - Street 1:516 SE MORRISON ST
Practice Address - Street 2:SUITE 207
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2327
Practice Address - Country:US
Practice Address - Phone:503-239-1022
Practice Address - Fax:503-512-5850
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist