Healthcare Provider Details

I. General information

NPI: 1184040255
Provider Name (Legal Business Name): PIVOT HEALTH ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8810 SE SUNNYBROOK BLVD STE 100
CLACKAMAS OR
97015-6805
US

IV. Provider business mailing address

8810 SE SUNNYBROOK BLVD STE 100
CLACKAMAS OR
97015-6805
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-7373
  • Fax: 503-659-2276
Mailing address:
  • Phone: 503-607-2226
  • Fax: 503-659-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberAC60351775
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: TYLER NATHANIEL ANDRES
Title or Position: ACUPUNCTURIST
Credential: DAOM, LAC
Phone: 503-607-2226