Healthcare Provider Details

I. General information

NPI: 1134607732
Provider Name (Legal Business Name): REBECCA M HERRIN LAC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 SE STARK ST STE 105
GRESHAM OR
97030-2656
US

IV. Provider business mailing address

22400 SE STARK ST STE 105
GRESHAM OR
97030-2656
US

V. Phone/Fax

Practice location:
  • Phone: 971-409-9462
  • Fax:
Mailing address:
  • Phone: 971-409-9462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00691
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: REBECCA MARIE HERRIN
Title or Position: OWNER/ACUPUNCTURIST
Credential: LAC
Phone: 503-492-2600