=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679394787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATSA ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2024
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 690 N MAIN ST
-----------------------------------------------------
City | MOUNT ANGEL
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97362-9518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-550-9695
-----------------------------------------------------
Fax | 503-845-9350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 690 N MAIN ST
-----------------------------------------------------
City | MOUNT ANGEL
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97362-9518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-550-9695
-----------------------------------------------------
Fax | 503-845-9350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACUPUNCTURIST, OWNER
-----------------------------------------------------
Name | BOSTEN INGRAM
-----------------------------------------------------
Credential | MACOM, LAC
-----------------------------------------------------
Telephone | 541-550-9695
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------