MEDICARE: WANDERING STONE ACUPUNCTURE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033766001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WANDERING STONE ACUPUNCTURE LLC

Provider Business Mailing Address
First Line	:	1524 NE HANCOCK ST APT 2
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-4472
Country	:	US
Telephone Number	:	360-223-4533
Fax Number	:

Provider Business Practice Location Address
First Line	:	1524 NE HANCOCK ST APT 2
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-4472
Country	:	US
Telephone Number	:	360-223-4533
Fax Number	:

Authorized Official
Title or Position	:	LAC
Name	:	HOLLY ANN POLINKUS
Credential	:	LAC
Telephone Number	:	360-223-4533

Provider Enumeration Date	:	08/23/2019
Last Update Date	:	08/23/2019

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Directions to “WANDERING STONE ACUPUNCTURE LLC ” Practice Location

Language	Start Address	Practice Location

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