Healthcare Provider Details

I. General information

NPI: 1205130382
Provider Name (Legal Business Name): ANDREA Q VINTRO MS, RD, CSSD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 SW 158TH AVE # 160
BEAVERTON OR
97006-4952
US

IV. Provider business mailing address

2116 SW 19TH AVE
PORTLAND OR
97201-2352
US

V. Phone/Fax

Practice location:
  • Phone: 503-915-2555
  • Fax:
Mailing address:
  • Phone: 503-915-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1029
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: