=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154528594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AJA NGO LAC.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5319 SW WESTGATE DR #148
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97221-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-928-9916
-----------------------------------------------------
Fax | 503-383-9105
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5319 SW WESTGATE DR #148
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97221-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-928-9916
-----------------------------------------------------
Fax | 503-383-9105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC01105
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------