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General NPI Number Information
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NPI Number | 1942734736
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Entity Type | Organization
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Legal Business Name | MOM BY LJ
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Dates
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Enumeration Date | 04/18/2017
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Last Update Date | 04/18/2017
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Provider Practice Location Address
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Address Line | 2906 N WILLAMETTE BLVD
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City | PORTLAND
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State | OR
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Zip | 97217-4073
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Country | US
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Telephone | 917-715-9617
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Fax |
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Provider Business Mailing Address
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Address Line | 2906 N WILLAMETTE BLVD
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City | PORTLAND
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State | OR
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Zip | 97217-4073
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LISA HULICK
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Credential | LMT
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Telephone | 917-715-9617
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 1169
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License Number State | OR
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