Healthcare Provider Details

I. General information

NPI: 1992063895
Provider Name (Legal Business Name): MALIA SUSEE, L.AC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 NE 28TH AVE
PORTLAND OR
97232-3150
US

IV. Provider business mailing address

316 NE 28TH AVE
PORTLAND OR
97232-3150
US

V. Phone/Fax

Practice location:
  • Phone: 503-230-0812
  • Fax: 503-233-9151
Mailing address:
  • Phone: 503-230-0812
  • Fax: 503-233-9151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01034
License Number StateOR

VIII. Authorized Official

Name: MALIA TARIE SUSEE
Title or Position: OWNER
Credential: L.AC.
Phone: 503-816-1278