Healthcare Provider Details

I. General information

NPI: 1801166384
Provider Name (Legal Business Name): KJELL MOLINE, L.AC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 SW 6TH AVE SUITE 801
PORTLAND OR
97204-1533
US

IV. Provider business mailing address

506 SW 6TH AVE SUITE 801
PORTLAND OR
97204-1533
US

V. Phone/Fax

Practice location:
  • Phone: 503-241-6505
  • Fax: 503-296-2205
Mailing address:
  • Phone: 503-241-6505
  • Fax: 503-296-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01254
License Number StateOR

VIII. Authorized Official

Name: MR. KJELL CAMERON MOLINE
Title or Position: OWNER
Credential: L.AC.
Phone: 503-241-6505