Healthcare Provider Details

I. General information

NPI: 1306312764
Provider Name (Legal Business Name): KATE DRAKE LAC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 SE DIVISION ST
PORTLAND OR
97202
US

IV. Provider business mailing address

3101 SE 20TH AVE
PORTLAND OR
97202-2313
US

V. Phone/Fax

Practice location:
  • Phone: 971-295-9751
  • Fax:
Mailing address:
  • Phone: 971-295-9751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE ELIZABETH DRAKE
Title or Position: OWNER
Credential: LAC
Phone: 971-295-9751