Healthcare Provider Details

I. General information

NPI: 1922303270
Provider Name (Legal Business Name): ADDIE HARBIN ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 NE HOOD AVE
GRESHAM OR
97030-5612
US

IV. Provider business mailing address

703 NE HOOD AVE
GRESHAM OR
97030-5612
US

V. Phone/Fax

Practice location:
  • Phone: 503-512-8663
  • Fax: 503-512-8632
Mailing address:
  • Phone: 503-512-8663
  • Fax: 503-512-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01216
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier139-699-0982
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNPI NUMBER

VIII. Authorized Official

Name: ADDIE R HARBIN
Title or Position: LICENSED ACUPUNCTURIST, OWNER
Credential: LAC, MACOM
Phone: 503-512-8663