Healthcare Provider Details

I. General information

NPI: 1558754630
Provider Name (Legal Business Name): YIBIN HUANG LAC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 NE GLISAN ST
PORTLAND OR
97220-2228
US

IV. Provider business mailing address

11111 NE GLISAN ST
PORTLAND OR
97220-2228
US

V. Phone/Fax

Practice location:
  • Phone: 503-688-9399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberAC170404
License Number StateOR

VIII. Authorized Official

Name: YIBIN HUANG
Title or Position: ACUPUNCTURIST
Credential:
Phone: 503-688-9399