Basic Information
| Provider Information | |||||||||
| NPI: | 1134736168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LU | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | THI | ||||||||
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| Credential: | CRM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1484 PRAIRIE CLOVER AVE NE | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973031713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712393893 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2045 SILVERTON RD NE STE 2100 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885358 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2020 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | OR | Y |
No ID Information.