Provider Demographics
NPI:1285166322
Name:COLLEEN GIBSON ACUPUNCTURE LLC
Entity type:Organization
Organization Name:COLLEEN GIBSON ACUPUNCTURE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:FRIDL
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-370-9073
Mailing Address - Street 1:3735 SE 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3005
Mailing Address - Country:US
Mailing Address - Phone:503-730-9073
Mailing Address - Fax:
Practice Address - Street 1:4004 SE WOODSTOCK BLVD # 5
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7662
Practice Address - Country:US
Practice Address - Phone:503-777-0444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01136171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641110Medicaid