Provider Demographics
NPI:1053961698
Name:DYNAMIC ACUPUNCTURE LLC
Entity type:Organization
Organization Name:DYNAMIC ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-686-3059
Mailing Address - Street 1:1829 NE ALBERTA ST STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-5889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1829 NE ALBERTA ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-5889
Practice Address - Country:US
Practice Address - Phone:503-893-5711
Practice Address - Fax:503-296-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500721654Medicaid