Provider Demographics
NPI:1992063895
Name:MALIA SUSEE, L.AC.
Entity type:Organization
Organization Name:MALIA SUSEE, L.AC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALIA
Authorized Official - Middle Name:TARIE
Authorized Official - Last Name:SUSEE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-816-1278
Mailing Address - Street 1:316 NE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3150
Mailing Address - Country:US
Mailing Address - Phone:503-230-0812
Mailing Address - Fax:503-233-9151
Practice Address - Street 1:316 NE 28TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3150
Practice Address - Country:US
Practice Address - Phone:503-230-0812
Practice Address - Fax:503-233-9151
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MALIA SUSEE, L.AC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01034171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty