Provider Demographics
NPI:1154969947
Name:MIRACLE, LORI KRISTEN (LAC)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:KRISTEN
Last Name:MIRACLE
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 1:3123 N WILLAMETTE BLVD APT 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4080
Mailing Address - Country:US
Mailing Address - Phone:971-808-9186
Mailing Address - Fax:
Practice Address - Street 1:KWAN YIN HEALING ARTS CENTER EAST INC
Practice Address - Street 2:3115 NE SANDY BLVD. SUITE 231
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-701-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC196256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist