Healthcare Provider Details

I. General information

NPI: 1588966402
Provider Name (Legal Business Name): AIMEE LYNN LESIEUTRE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 S. 10TH ST.
PHILOMATH OR
97370
US

IV. Provider business mailing address

PO BOX 14
PHILOMATH OR
97370-0014
US

V. Phone/Fax

Practice location:
  • Phone: 541-929-3203
  • Fax:
Mailing address:
  • Phone: 541-929-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC150709
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: