=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700156411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAMBOO GARDENS ACUPUNCTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2012
-----------------------------------------------------
Last Update Date | 01/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 SW 185TH AVE
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97007-3081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-523-6512
-----------------------------------------------------
Fax | 503-579-9047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4700 SW 185TH AVE
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97007-3081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-523-6512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED ACUPUNCTURIST
-----------------------------------------------------
Name | MS. LINDA C FAUST
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 503-523-6512
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC00189
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------