Provider Demographics
NPI:1952600124
Name:MANDALA MEDICINE ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:MANDALA MEDICINE ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-758-9760
Mailing Address - Street 1:1020 SE 7TH AVE #14100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97293
Mailing Address - Country:US
Mailing Address - Phone:503-758-9760
Mailing Address - Fax:
Practice Address - Street 1:3125 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2073
Practice Address - Country:US
Practice Address - Phone:503-758-9760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-26
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC 152885171100000X
OR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty