Healthcare Provider Details

I. General information

NPI: 1275947723
Provider Name (Legal Business Name): LITTLE WING ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 SW 11TH AVE SUITE #1018
PORTLAND OR
97205-2125
US

IV. Provider business mailing address

833 SW 11TH AVE SUITE #1018
PORTLAND OR
97205-2125
US

V. Phone/Fax

Practice location:
  • Phone: 503-224-2525
  • Fax: 503-224-3397
Mailing address:
  • Phone: 503-224-2525
  • Fax: 503-224-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC156429
License Number StateOR

VIII. Authorized Official

Name: KEVI KEENOM
Title or Position: OWNER, PRACTITIONER
Credential: LAC, MACOM
Phone: 503-224-2525