MEDICARE: MOVING MOUNTAIN INSTITUTE, INC.

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	AC156717	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1578790226	OTHER	OR	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1669920864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOVING MOUNTAIN INSTITUTE, INC.

Provider Business Mailing Address
First Line	:	4203 SE HAWTHORNE BLVD
Second Line	:	SUITE A
City	:	PORTLAND
State	:	OR
Zip	:	97215-3160
Country	:	US
Telephone Number	:	503-985-9625
Fax Number	:	888-958-0782

Provider Business Practice Location Address
First Line	:	4203 SE HAWTHORNE BLVD
Second Line	:	SUITE A
City	:	PORTLAND
State	:	OR
Zip	:	97215-3160
Country	:	US
Telephone Number	:	503-985-9625
Fax Number	:	888-958-0782

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	MICHAEL MCMAHON
Credential	:	L.AC, LMT
Telephone Number	:	503-985-9625

Provider Enumeration Date	:	09/15/2016
Last Update Date	:	09/15/2016

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