Provider Demographics
NPI:1841927316
Name:INGRAM, BOSTEN (LAC)
Entity type:Individual
Prefix:
First Name:BOSTEN
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4466 BRIAR KNOB LOOP NE
Mailing Address - Street 2:
Mailing Address - City:SCOTTS MILLS
Mailing Address - State:OR
Mailing Address - Zip Code:97375-9637
Mailing Address - Country:US
Mailing Address - Phone:541-550-9695
Mailing Address - Fax:
Practice Address - Street 1:306 OAK ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1719
Practice Address - Country:US
Practice Address - Phone:503-874-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC212490171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist