MEDICARE: MALEA MACODRUM N.D., M.S.O.M.

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
2	175F00000X	Naturopath

General Provider Information

NPI Number	:	1700288669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALEA MACODRUM N.D., M.S.O.M.

Provider Business Mailing Address
First Line	:	3718 SE 33RD PL
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-3056
Country	:	US
Telephone Number	:	503-754-5397
Fax Number	:

Provider Business Practice Location Address
First Line	:	516 SE MORRISON ST
Second Line	:	SUITE 207
City	:	PORTLAND
State	:	OR
Zip	:	97214-2327
Country	:	US
Telephone Number	:	503-239-1022
Fax Number	:	503-512-5850

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

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	11/06/2014

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Directions to “ MALEA MACODRUM N.D., M.S.O.M.” Practice Location

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