Healthcare Provider Details

I. General information

NPI: 1285166322
Provider Name (Legal Business Name): COLLEEN GIBSON ACUPUNCTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 SE WOODSTOCK BLVD # 5
PORTLAND OR
97202-7662
US

IV. Provider business mailing address

3735 SE 27TH AVE
PORTLAND OR
97202-3005
US

V. Phone/Fax

Practice location:
  • Phone: 503-777-0444
  • Fax:
Mailing address:
  • Phone: 503-730-9073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01136
License Number StateOR

VIII. Authorized Official

Name: COLLEEN FRIDL GIBSON
Title or Position: OWNER
Credential: L.AC.
Phone: 503-370-9073