Provider Demographics
NPI:1992944029
Name:COLLEEN DONNELLY ACUPUNCTURE, LLC
Entity type:Organization
Organization Name:COLLEEN DONNELLY ACUPUNCTURE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-705-1812
Mailing Address - Street 1:3105 SE 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-2035
Mailing Address - Country:US
Mailing Address - Phone:503-705-1812
Mailing Address - Fax:
Practice Address - Street 1:2601 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2317
Practice Address - Country:US
Practice Address - Phone:503-232-1948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01247171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty