Healthcare Provider Details

I. General information

NPI: 1487325445
Provider Name (Legal Business Name): CLEO ALAIA WEST RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW 167TH PL STE 230
BEAVERTON OR
97006-4872
US

IV. Provider business mailing address

6135 SE HEIKE ST
HILLSBORO OR
97123-8237
US

V. Phone/Fax

Practice location:
  • Phone: 800-424-6589
  • Fax:
Mailing address:
  • Phone: 646-696-1096
  • Fax: 503-566-6067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10217067
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: