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General NPI Number Information
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NPI Number | 1053763466
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Entity Type | Organization
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Legal Business Name | ANCIENT FERN MEDICINE
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Dates
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Enumeration Date | 07/08/2016
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Last Update Date | 07/08/2016
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Provider Practice Location Address
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Address Line | 2926 NE FLANDERS ST STE 2C
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City | PORTLAND
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State | OR
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Zip | 97232-3259
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Country | US
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Telephone | 971-227-2773
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Fax | 971-275-1961
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Provider Business Mailing Address
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Address Line | 2926 NE FLANDERS ST STE 2C
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City | PORTLAND
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State | OR
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Zip | 97232-3259
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Country | US
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Telephone | 971-227-2773
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Fax | 971-275-1961
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Authorized Official
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Title or Position | OWNER
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Name | TIMOTHY NICHOLAS NELSON
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Credential | L.AC.
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Telephone | 971-227-2773
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC161759
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License Number State | OR
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