Healthcare Provider Details

I. General information

NPI: 1609579879
Provider Name (Legal Business Name): MORGAN COSTLEY LAC LMT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 NW 167TH PL STE 100
BEAVERTON OR
97006-4908
US

IV. Provider business mailing address

2503 NE 59TH AVE
PORTLAND OR
97213-4011
US

V. Phone/Fax

Practice location:
  • Phone: 503-560-0843
  • Fax:
Mailing address:
  • Phone: 503-560-0843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MORGAN COSTLEY
Title or Position: LICENSED ACUPUNCTURIST
Credential: LAC LMT
Phone: 503-560-0843