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NPI Code Detail

MEDICARE: FERTILE GROUND FAMILY CENTER, LLC

MEDICARE: FERTILE GROUND FAMILY CENTER, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QB0400XBirthing Clinic/CenterDEM-LD-10144749OR
2261QP2300XPrimary Care Clinic/Center2921OR

General Provider Information

NPI Number : 1558607812
Entity Type Code : Organization
Provider Name (Legal Business Name) : FERTILE GROUND FAMILY CENTER, LLC
Provider Business Mailing Address
First Line : 3575 NE BROADWAY ST
Second Line :
City : PORTLAND
State : OR
Zip : 97232-1820
Country : US
Telephone Number : 503-284-6195
Fax Number :
Provider Business Practice Location Address
First Line : 3575 NE BROADWAY ST
Second Line :
City : PORTLAND
State : OR
Zip : 97232-1820
Country : US
Telephone Number : 503-284-6195
Fax Number :
Authorized Official
Title or Position : DIRECTOR
Name : DR. CAROLINE PETERSON
Credential : DC, PHD, MPH, LDM
Telephone Number : 503-284-6195
Provider Enumeration Date : 12/13/2012
Last Update Date : 12/13/2012

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Directions to “FERTILE GROUND FAMILY CENTER, LLC ” Practice Location

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