MEDICARE: MS. LYDIA DIANE TATE LAC

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	AC208176	OR

General Provider Information

NPI Number	:	1962161000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LYDIA DIANE TATE LAC

Provider Business Mailing Address
First Line	:	4035 SE 52ND AVE STE B
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-3913
Country	:	US
Telephone Number	:	971-229-2140
Fax Number	:

Provider Business Practice Location Address
First Line	:	4035 SE 52ND AVE STE B
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-3913
Country	:	US
Telephone Number	:	971-229-2140
Fax Number	:

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

Provider Enumeration Date	:	12/16/2021
Last Update Date	:	12/16/2021

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