MEDICARE: BENJAMIN MAGGA M.AC.O.M., L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC153377	OR

General Provider Information

NPI Number	:	1164721973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN MAGGA M.AC.O.M., L.AC.

Provider Business Mailing Address
First Line	:	4203 SE HAWTHORNE BLVD
Second Line	:	STE A
City	:	PORTLAND
State	:	OR
Zip	:	97215-3160
Country	:	US
Telephone Number	:	503-233-4102
Fax Number	:

Provider Business Practice Location Address
First Line	:	4203 SE HAWTHORNE BLVD
Second Line	:	STE A
City	:	PORTLAND
State	:	OR
Zip	:	97215-3160
Country	:	US
Telephone Number	:	503-233-4102
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2011
Last Update Date	:	03/18/2011

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