MEDICARE: GREEN WILLOW ACUPUNCTURE, LLC

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

General Provider Information

NPI Number	:	1174980809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN WILLOW ACUPUNCTURE, LLC

Provider Business Mailing Address
First Line	:	911 NE 4TH ST
Second Line	:	SUITE 2
City	:	BEND
State	:	OR
Zip	:	97701-4647
Country	:	US
Telephone Number	:	541-678-1162
Fax Number	:	512-493-6178

Provider Business Practice Location Address
First Line	:	911 NE 4TH ST
Second Line	:	SUITE 2
City	:	BEND
State	:	OR
Zip	:	97701-4647
Country	:	US
Telephone Number	:	541-678-1162
Fax Number	:	512-493-6178

Authorized Official
Title or Position	:	MEMBER
Name	:	EMDEN GRIFFIN
Credential	:	LAC
Telephone Number	:	541-350-0723

Provider Enumeration Date	:	01/26/2016
Last Update Date	:	01/28/2016

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