Provider Demographics
NPI:1982092276
Name:EARTH-MOON ACUPUNCTURE, INC.
Entity Type:Organization
Organization Name:EARTH-MOON ACUPUNCTURE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-939-5541
Mailing Address - Street 1:2365 GREAR ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2747
Mailing Address - Country:US
Mailing Address - Phone:503-383-9796
Mailing Address - Fax:971-273-6658
Practice Address - Street 1:2365 GREAR ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2747
Practice Address - Country:US
Practice Address - Phone:503-383-9796
Practice Address - Fax:971-273-6658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150966261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500687546Medicaid