Healthcare Provider Details

I. General information

NPI: 1760751044
Provider Name (Legal Business Name): GABRIEL STEVEN PREWITT L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 SE SUNNYSIDE RD STE 204
CLACKAMAS OR
97015-9704
US

IV. Provider business mailing address

3847 MEADOWLAWN LOOP SE APT 6
SALEM OR
97317-5358
US

V. Phone/Fax

Practice location:
  • Phone: 503-730-4203
  • Fax:
Mailing address:
  • Phone: 503-730-4203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC156435
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: