Healthcare Provider Details

I. General information

NPI: 1073247888
Provider Name (Legal Business Name): PACIFICEMDR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2022
Last Update Date: 07/16/2022
Certification Date: 07/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 SW BEAVERTON HILLSDALE HWY STE 560
BEAVERTON OR
97005-4791
US

IV. Provider business mailing address

2034 COLUMBIA BLVD # 154
SAINT HELENS OR
97051-1737
US

V. Phone/Fax

Practice location:
  • Phone: 971-341-7542
  • Fax:
Mailing address:
  • Phone: 971-341-7542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS LILY DAVIS
Title or Position: OWNER
Credential: LCSW
Phone: 971-341-7542