Healthcare Provider Details

I. General information

NPI: 1629368196
Provider Name (Legal Business Name): ALEXIS MIRANDA LIVELY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date: 12/08/2020
Reactivation Date: 02/03/2021

III. Provider practice location address

210 NW 17TH AVE STE 201
PORTLAND OR
97209-2151
US

IV. Provider business mailing address

210 NW 17TH AVE STE 201
PORTLAND OR
97209-2151
US

V. Phone/Fax

Practice location:
  • Phone: 503-207-3449
  • Fax:
Mailing address:
  • Phone: 503-207-3449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC202639
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17304
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: