Provider Demographics
NPI:1861596074
Name:BOURLAND, ILEANA (MSOM LICAC)
Entity type:Individual
Prefix:MISS
First Name:ILEANA
Middle Name:
Last Name:BOURLAND
Suffix:
Gender:F
Credentials:MSOM LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 NE IRVING AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4710
Mailing Address - Country:US
Mailing Address - Phone:512-736-6122
Mailing Address - Fax:541-617-0377
Practice Address - Street 1:334 NE IRVING AVE
Practice Address - Street 2:STE 102
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4710
Practice Address - Country:US
Practice Address - Phone:512-736-6122
Practice Address - Fax:541-617-0377
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC153140171100000X
TXAC00534171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist