=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306145735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WIND AND WATER ACUPUNCTURE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2011
-----------------------------------------------------
Last Update Date | 03/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5421 NE 33RD AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97211-7403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-720-1258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 NE JUNIOR ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97211-4147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-720-1258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST
-----------------------------------------------------
Name | MS. ALISHA MARIE HARRINGTON
-----------------------------------------------------
Credential | LAC, LMT
-----------------------------------------------------
Telephone | 503-720-1258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC153161
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------