Healthcare Provider Details

I. General information

NPI: 1588107718
Provider Name (Legal Business Name): LUMINOUS LIFE ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2016
Last Update Date: 11/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N MAIN AVE STE 201
GRESHAM OR
97030-7200
US

IV. Provider business mailing address

15235 SE MARKET CT
PORTLAND OR
97233-3345
US

V. Phone/Fax

Practice location:
  • Phone: 503-502-4190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC180192
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ARIANNE SIERRA KELLER
Title or Position: ACUPUNCTURIST/OWNER
Credential: LAC
Phone: 503-502-4190