Provider Demographics
NPI:1770123739
Name:AMSDEN, FOREST (LAC, MACOM)
Entity type:Individual
Prefix:
First Name:FOREST
Middle Name:
Last Name:AMSDEN
Suffix:
Gender:M
Credentials:LAC, MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2066 NW OVERTON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1654
Mailing Address - Country:US
Mailing Address - Phone:541-285-2366
Mailing Address - Fax:
Practice Address - Street 1:1033 SW YAMHILL ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2539
Practice Address - Country:US
Practice Address - Phone:503-222-1315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC190822171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist