Provider Demographics
NPI:1538884481
Name:CALDERA ACUPUNCTURE LLC
Entity type:Organization
Organization Name:CALDERA ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:541-961-7947
Mailing Address - Street 1:19926 PORCUPINE DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2090
Mailing Address - Country:US
Mailing Address - Phone:541-961-7947
Mailing Address - Fax:
Practice Address - Street 1:1045 NW BOND ST STE 202
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2064
Practice Address - Country:US
Practice Address - Phone:541-961-7947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR205587OtherSTATE LICENSE
MT99088OtherSTATE LICENSE