Healthcare Provider Details

I. General information

NPI: 1720940091
Provider Name (Legal Business Name): DEUT 1111
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10478 SW MOUNT ADAMS DR
BEAVERTON OR
97007-8379
US

IV. Provider business mailing address

10478 SW MOUNT ADAMS DR
BEAVERTON OR
97007-8379
US

V. Phone/Fax

Practice location:
  • Phone: 971-762-3132
  • Fax: 971-762-3132
Mailing address:
  • Phone: 971-762-3132
  • Fax: 971-762-3132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: TAMARA ALFONSO
Title or Position: OWNER
Credential:
Phone: 971-762-3132