Healthcare Provider Details

I. General information

NPI: 1013350065
Provider Name (Legal Business Name): MANDALA ACUPUNCTURE & BODYWORK. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 NW DAVIS ST
PORTLAND OR
97209-3103
US

IV. Provider business mailing address

925 NW DAVIS ST
PORTLAND OR
97209-3103
US

V. Phone/Fax

Practice location:
  • Phone: 503-341-6459
  • Fax:
Mailing address:
  • Phone: 503-341-6459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: UMA TUPPER
Title or Position: OWNER
Credential: LAC, LMT
Phone: 503-341-6459