Healthcare Provider Details

I. General information

NPI: 1346213204
Provider Name (Legal Business Name): MARYA EDEN DEDA LAC, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2933 NE BROADWAY ST
PORTLAND OR
97232-1760
US

IV. Provider business mailing address

2933 NE BROADWAY ST
PORTLAND OR
97232-1760
US

V. Phone/Fax

Practice location:
  • Phone: 503-282-2268
  • Fax: 503-282-2863
Mailing address:
  • Phone: 503-282-2268
  • Fax: 503-282-2863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00978
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: