Provider Demographics
NPI:1801170196
Name:BONNICHSEN, CHRISTOPHER MICHAEL (LAC MAOAM)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:BONNICHSEN
Suffix:
Gender:M
Credentials:LAC MAOAM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 SE HAWTHORNE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3170
Mailing Address - Country:US
Mailing Address - Phone:503-998-6357
Mailing Address - Fax:
Practice Address - Street 1:4511 SE HAWTHORNE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3170
Practice Address - Country:US
Practice Address - Phone:503-998-6357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC153361171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist