Provider Demographics
NPI:1487064028
Name:LUONG, MAI (RD)
Entity type:Individual
Prefix:MRS
First Name:MAI
Middle Name:
Last Name:LUONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 SW WASHINGTON ST
Mailing Address - Street 2:PO BOX 3007
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2327
Mailing Address - Country:US
Mailing Address - Phone:503-535-1177
Mailing Address - Fax:503-535-1191
Practice Address - Street 1:1320 SW WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2327
Practice Address - Country:US
Practice Address - Phone:503-535-1177
Practice Address - Fax:503-535-1191
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR805464133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered