Provider Demographics
NPI:1669873154
Name:BROOKLYN COMMUNITY ACUPUNCTURE AND WELLNESS, LLC
Entity type:Organization
Organization Name:BROOKLYN COMMUNITY ACUPUNCTURE AND WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:VERA
Authorized Official - Last Name:BRINK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:310-773-6649
Mailing Address - Street 1:3205 SE 13TH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2461
Mailing Address - Country:US
Mailing Address - Phone:503-233-4341
Mailing Address - Fax:
Practice Address - Street 1:3205 SE 13TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2461
Practice Address - Country:US
Practice Address - Phone:503-233-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC156229171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty