Healthcare Provider Details

I. General information

NPI: 1639351067
Provider Name (Legal Business Name): TARA CRISHANN NIKZI MAC. OM.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 SW SPRING GARDEN ST STE 100
PORTLAND OR
97219-3966
US

IV. Provider business mailing address

2505 SW SPRING GARDEN ST STE 100
PORTLAND OR
97219-3966
US

V. Phone/Fax

Practice location:
  • Phone: 503-841-6222
  • Fax: 503-841-6199
Mailing address:
  • Phone: 503-841-6222
  • Fax: 503-841-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01146
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: