Provider Demographics
NPI:1902154974
Name:WASHOUGAL ACUPUNCTURE AND MASSAGE, LLC
Entity Type:Organization
Organization Name:WASHOUGAL ACUPUNCTURE AND MASSAGE, LLC
Other - Org Name:WASHOUGAL ACUPUNCTURE AND MASSAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-367-7823
Mailing Address - Street 1:1436 A ST
Mailing Address - Street 2:STE 105
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-2378
Mailing Address - Country:US
Mailing Address - Phone:360-207-0134
Mailing Address - Fax:360-208-0520
Practice Address - Street 1:1436 A ST
Practice Address - Street 2:STE 105
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-2378
Practice Address - Country:US
Practice Address - Phone:360-207-0134
Practice Address - Fax:360-208-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-24
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 60619873171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500638844Medicaid