Provider Demographics
NPI:1396092573
Name:GREEN LOTUS ACUPUNCTURE, LLC
Entity type:Organization
Organization Name:GREEN LOTUS ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-789-7661
Mailing Address - Street 1:1208 SE LAMBERT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6369
Mailing Address - Country:US
Mailing Address - Phone:503-789-7661
Mailing Address - Fax:
Practice Address - Street 1:2100 SE LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7759
Practice Address - Country:US
Practice Address - Phone:503-789-7661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC153318171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty