Provider Demographics
NPI:1932748035
Name:MALIA SUSEE, L.AC, MACOM, DIPL.OM
Entity Type:Organization
Organization Name:MALIA SUSEE, L.AC, MACOM, DIPL.OM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSEE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, MACOM, DIPLOM
Authorized Official - Phone:503-272-1550
Mailing Address - Street 1:4410 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2331
Mailing Address - Country:US
Mailing Address - Phone:503-272-1550
Mailing Address - Fax:503-234-6338
Practice Address - Street 1:4410 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2331
Practice Address - Country:US
Practice Address - Phone:503-272-1550
Practice Address - Fax:503-234-6338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500818178Medicaid