MEDICARE: TRISTA L. JOLLY MAOM, L.AC.

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	AC01171	OR

General Provider Information

NPI Number	:	1952589129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRISTA L. JOLLY MAOM, L.AC.

Provider Business Mailing Address
First Line	:	1142 SE 52ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97215-2633
Country	:	US
Telephone Number	:	503-703-3197
Fax Number	:

Provider Business Practice Location Address
First Line	:	3234 NE WASCO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1981
Country	:	US
Telephone Number	:	503-703-3197
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2008
Last Update Date	:	02/09/2008

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