Source Integrative Medicine LLC

Primary specialty

AcupuncturistTaxonomy code 171100000X

License

AC165411 Issued in OR

Legal business name

SOURCE INTEGRATIVE MEDICINE LLC

Practice address

4424 NE Glisan St
Portland, OR 97213-2331

Phone

(503) 928-6728

Fax

(503) 296-5917

NPI assigned

Jul 21, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dara Cantor, L.AC

Title

Owner

Phone

(503) 928-6728

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1437436800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1438819200000",
    "number": "1275918278",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4424 NE GLISAN ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972132331",
            "telephone_number": "503-928-6728",
            "fax_number": "503-296-5917"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4424 NE GLISAN ST",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972132331",
            "telephone_number": "503-928-6728",
            "fax_number": "503-296-5917"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOURCE INTEGRATIVE MEDICINE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-21",
        "last_updated": "2015-08-06",
        "status": "A",
        "authorized_official_last_name": "CANTOR",
        "authorized_official_first_name": "DARA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "503-928-6728",
        "authorized_official_credential": "L.AC"
    },
    "taxonomies": [
        {
            "code": "171100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Acupuncturist",
            "state": "OR",
            "license": "AC165411",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Acupuncturist in Portland, OR
• Providers in Portland, OR by specialty
• Acupuncturist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 6, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.