Provider Demographics
NPI:1992315626
Name:PORTLAND PEDIATRIC ACUPUNCTURE
Entity type:Organization
Organization Name:PORTLAND PEDIATRIC ACUPUNCTURE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:971-337-7387
Mailing Address - Street 1:3308 SE LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2305 SE 50TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3853
Practice Address - Country:US
Practice Address - Phone:503-946-8605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center