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General NPI Number Information
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NPI Number | 1659630762
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Entity Type | Organization
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Legal Business Name | VITALIZE ACUPUNCTURE AND HERBAL MEDICINE, LLC
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Dates
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Enumeration Date | 05/09/2012
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Last Update Date | 05/09/2012
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Provider Practice Location Address
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Address Line | 511 SW 10TH AVE STE 610
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City | PORTLAND
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State | OR
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Zip | 97205-2707
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Country | US
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Telephone | 503-756-2743
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Fax |
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Provider Business Mailing Address
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Address Line | 511 SW 10TH AVE STE 610
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City | PORTLAND
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State | OR
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Zip | 97205-2707
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Country | US
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Telephone | 503-756-2743
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA GILCHRIST
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Credential |
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Telephone | 503-756-2743
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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 | AC156204
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License Number State | OR
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